|
1 To Be Competed /Verified By: FUNERAL DIRECTOR
<br />1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Data of Death (MO /Day/Vr) (Spell Mo)
<br />Harold Mitchell Green M ale 1317 -46 -4028 ( February 4,2014
<br />5a. Age -Last Birthday (Vrs)
<br />64
<br />50. Under 1 Yea
<br />Sc. Under 1 Day 6. Date of Birth (MO /Day/Veer) (Spell Month)
<br />J BSrthplace (C� Ity an State or Foreign Country)
<br />I 1 W O O a ( S n d i a n a
<br />Months 1 D ys
<br />Hours I Miny[eb I
<br />I I S eptember 21 , 1949
<br />7b. Birthplace (County) Madison
<br />8a. Residence (State or Foreign Country)
<br />Nebraska
<br />80. Residence (Street and Number - Include Apt No.)
<br />382 1 W. S t o 1 1 e y P a r k R d.
<br />8c. Did Decedent Live Ina Township?
<br />D Yes, decedent lived In two.
<br />ed. Residence (County)
<br />H a 11
<br />ao No, decedent lived within limits of G r Ft n it T w 7 a n A ci /bore.
<br />8e. Residence (Zip Code) 6 R R n 3
<br />9. E ver In US Armed Forces? 10. Mar
<br />ao Yes D No D Unknown 1 0 Divorced
<br />tel Status at Time of Death Married 0 Widowed 1 11. Surviving Spouse's Name (If wife, give name prior to first marriage)
<br />0 Never Married D Unknown Rena S w a d l e y
<br />12. Father's Name (First, Middle, Last, Suffix)
<br />Dirwood Green
<br />13. Mother's Name Prior to First Marriage (First, Middle, Lest)
<br />Ina Netherton
<br />142. Informant's Name 14b. Relationship to Decedent
<br />Rena Green Wife
<br />141. Informant's Mailing Address (Street and Number, City, State, Zip Cotlee�,,
<br />3821 W.Stolle Park Rd. Grandl
<br />16� o Deat ec on
<br />If Death Occurred in a Hospital: Inpatient If Death Occurred Somewhere Other T
<br />LSO Than a Hospital: 0 Hospice Facility in Decedent's Home
<br />D Emergency Room /Outpatient 0 Dead on Arrival D Nursing Home /Long -Term Care Facility D Other (Specify)
<br />150. Facility Name (If not Institution, glue street and number)
<br />VAPHS #646University Dr.0
<br />15c. City or Town, State, and Zip Cotle lStl. County of Death
<br />Pittsburgh PA 15240 I All eghw
<br />168. Method of Disposition Ga Burial O Cremation
<br />Removal from State 7� D Donation
<br />D Other (Specify)
<br />16b. Date of Disposition
<br />Feb10 , 2014
<br />16c. Place of Disposition (Name of cemetery, crematory, or other place)
<br />Grand Island City Cemetery
<br />16d. Location of Disposition (City or Town, State, and Zip)
<br />Grandlsland NE 68803
<br />1 Signature of Funeral Service Licensee or Person In Charge of Interment
<br />0- 71i, CEP,
<br />17b. License Number
<br />FD011449L
<br />17c. Name and Complete Address of Funeral Facility
<br />McCabe Funeral Home, 300 W bird Avenue. Derry. PA 15627
<br />18. Decedent's Education - Check the box that best describes the
<br />highest degree or level of school completed at the time of death.
<br />D 8th grade or less
<br />0 No diploma, 9th - 12th grade
<br />D High school graduate or GEO completed
<br />klg Some college credit, but no degree
<br />D Associate degree (e.g. AA, AS)
<br />D Bachelor's degree (e.g. BA, AB, BS)
<br />D Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA)
<br />D Doctorate (e.g. PhD, Edo) or Professional degree
<br />(e.g. MD, DOS, DVNI, LLB, JD)
<br />19. Decedent of Hispanic Origin - Check the
<br />box that best describes whether the decedent
<br />is Spanish /Hispanic /Latino. Check the "NO"
<br />box If decedent Is not Spanish /Hispanic /Latino.
<br />dt No not Spanish /Hispanic /Latino
<br />D Yes, Mexlcan, Mexican American, Chicano
<br />0 Yes, Puerto Rican
<br />D Yes, Cuban
<br />0 Yes, other Spanish /Hispanic /Latino
<br />(Specify)
<br />20. Decedent's Race - Check ONE OR MORE races to Indicate what
<br />the decedent considered himself or herself to be.
<br />Oa White 0 Korean
<br />D Black or African American D Vietnamese
<br />0 American Indian or Alaska Native 0 Other Asian
<br />D Asian Indian D Native Hawaiian
<br />D Chinese D Guamanian or Chamorro
<br />0 Filipino 0 Sarno n
<br />0 Japanese D Other Pacific Islander
<br />O Other (Specify)
<br />21. Decedent's Single Race Self - Designation - Check ONLY 0N5 to indicate what the decedent considered himself or herself to be.
<br />IX White D Japanese 0 Samoan
<br />D Black or African American D Korean D Other Pacific Islander
<br />D American Indian or Alaska Native D Vietnamese D Don't Know /Not Sure
<br />O Asian Indian D Other Asian 0 Refused
<br />D Chinese 0 Native Hawaiian D Other (Specify)
<br />22a. Decedent's Usual Occupation - Indicate type of work
<br />done during most of working life. DO NOT USE RETIRED.
<br />Utility T e c h n i c i a n
<br />22b. Kind of Business /Industry
<br />.�., i t Utility i ]- i t Department
<br />y y
<br />0 Filipino D Guamanian or Chamorro
<br />B3Ii123J NJ103W :AB Pala luo0 aR o f
<br />ITEMS 23a - 23d MUST BE COMPLETED
<br />BY PERSON WHO PRONOUNCES OR
<br />CERTIFIES DEATH
<br />23a. Date Pronounced Dead (MO /Day/Vr)
<br />February 4, 2 0 1 4
<br />23b. of Person Pronouncing Death (Only when applicable)
<br />23c. License Number
<br />MT 2 0 3 2 6 6
<br />23tl. Date Si (M D
<br />O/ay /YrLL
<br />February 4 2 0 14
<br />24. Time of Death S 1 3 p m
<br />_
<br />2S: was.. cal Examiner or Coroner Contacted? D Yes M No
<br />CAUSE OF DEATH
<br />26. Part 1. Enter the chain of events -- diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />Approximate
<br />Interval:
<br />Onset to Death
<br />5Days
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE Diffuse Alveolar Hemorrhage
<br />e.
<br />(Final disease or condition Due to (or as a consequence of):
<br />resulting In death) Coagulopathy Months
<br />b.
<br />Sequentially list conditions. Due to (or as a consequence of):
<br />ifany, n line
<br />o e line a. Enter the gtothecause
<br />listed ,Non- alcoholic steatohepatitis liver failure Years
<br />UNDERLYING CAUSE Due to (or as a consequence of):
<br />(disease or InJury that
<br />Initiated the events resulting tl.
<br />in death) LAST. Due to (or as a consequence of):
<br />26. Part 11. Enter other significant conditions contributing to death{ but not resulting in the underlying cause given In Part I.
<br />27. Was an autopsy performed?
<br />0 Yes ao No
<br />28. Were autopsy findings available
<br />to complete the cause of death?
<br />D Yes co No
<br />29. If Female:
<br />D Not pregnant within past year
<br />0 Pregnant at time of death
<br />D Not pregnant, but pregnant within 42 days of death
<br />D Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown If pregnant within the past veer
<br />30. Did Tobacco Use Contribute to Death?
<br />D Yes D Probably
<br />D No DO Unknown
<br />31. Manner of Dee h
<br />Natural D Homicide
<br />0 Accident D Pending Investigation
<br />0
<br />0 Suicide 0 Could not be determined
<br />32. Date o Injury (MO /Day /Yr) (Spell Month)
<br />33. Time of Injury
<br />34. Place of InJury (e.g. home; construction site; farm; school)
<br />35. Location of Injury (Street and Number, City, County, State, Zip Code)
<br />36. Injury at Work
<br />D Yes
<br />D 00
<br />37. If Transportation Injury, Specify:
<br />D Driver /Operator 0 Pedestrian
<br />D Passenger D Other (Specify)
<br />38. Describe How Injury Occurred:
<br />39e. Certifier - physician, certified nurse practitioner, medical examiner /coroner (Check
<br />D Certifying only - To the best of my knowledge, death occurred due to the cause(s)
<br />IX Pronouncing & Certifying - 0 the best of n,y knowledge, death occurred at the time,
<br />O Medical Examiner /Co OO.the of examination and /or Investigation, In my
<br />Signature of certifier: - Title
<br />only one):
<br />and manner stated.
<br />date, and place, and due to the cause(s) and manner stated.
<br />opinion, death occurred at the time, date, and place, and due to the cause(s) and manner stated.
<br />of certifier: MD License Number: M 2 0 3 2 6 6
<br />39b. Name, Address and Zip Code of Person Completing Cause of Death (Item 26) 1 5 2 4 0
<br />Erie Suess MD,VAPHS # 646 ,UniversityDr.C,Pittsburgh,PA
<br />39c. Date Signed (Mo /Day/Yr)
<br />February4,2014
<br />40. Registrar's Distil Number �,
<br />S
<br />141. Re a -
<br />4 IStrar; r ,
<br />43. Amen tl ments
<br />5.805 REV (9 /I1)
<br />e for this certificate, $6.00
<br />Ce
<br />P 20367756
<br />Certification Number
<br />Type /Print In
<br />Permanent
<br />Black Ink
<br />8
<br />LOCAL REGISTRAR'S CERTIFICATION OF DEATH
<br />WARNING: It is illegal to duplicate this copy by photostat or photograph.
<br />201401250
<br />Loca Registrar
<br />COMMONWEALTH OF PENNSYLVANIA . DEPARTMENT OF HEALTH - VITAL RECORDS
<br />CERTIFICATE OF DEATH _ _ __ •
<br />Disposition Permit No. 9 8 4 8 0 3
<br />This is to certify that the information here given is
<br />correctly copied from an original Certificate of Death
<br />duly filed with me as Local Registrar. The original
<br />certificate will be forwarded to the State Vital
<br />Rec ±rds Office for permanent filing.
<br />H105 -143
<br />REV 07/2012
<br />
|