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To be completed/verified by: FUNERAL DIRECTOR I
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix) 2
<br />2. SEX ' j '
<br />'3', DAT DEATH (Mo., Day, Yr.)
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5
<br />5a. AGE • Last Birthday 5
<br />5b. UNDER 1 YEAR 5
<br />5c. UNDER 1 DAY 6
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />MOS. D
<br />DAYS H
<br />HOURS M
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER 8
<br />8a. PLACE OF DEATH
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />8c. CITY OR TOWN OF DEATH (include Zip Code) 8
<br />8d. COUNTY OF DEATH
<br />9a. RESIDENCE-STATE 9
<br />9b. COUNTY 8
<br />8c. CITY OR TOWN
<br />9d. STREET AND NUMBER e
<br />e. APT. NO. 9
<br />9f. ZIP CODE 9
<br />9g. INSIDE CITY LIMITS
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 1
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 1
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. 1
<br />14a. INFORMANT -NAME 1
<br />14b. RELATIONSHIP TO DECEDENT
<br />15. METHOD OF DISPOSITION 1
<br />16a. EMBALMER-SIGNATURE 1
<br />16b. LICENSE NO. 1
<br />16c. DATE (Mo., Day, Yr.)
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 1
<br />17b. Zip Code
<br />CAUSE OF DEATH (See instructions and examples)
<br />To be completed by: CERTIFIER
<br />18. PART I. Enter the chain of events- - diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<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: onset to death
<br />IMMEDIATE CAUSE (Final a) Lewy Body Dementia Years
<br />disease or condition resulting
<br />In Beath) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Sequentially list conditions, if b)
<br />any, leading to the cause listed
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE C)
<br />(disease or injury that initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART I. 1
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES El NO
<br />20. IF FEMALE: 2
<br />215. MANNER OF DEATH 2
<br />21b. IF TRANSPORTATION INJURY 2
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 2
<br />22b. TIME OF INJURY 2
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK? 2
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />b W ' M
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 2
<br />.tg
<br />24a. DATE SIGNED (Mo., Day, Yr.) 2
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.) 1
<br />123c. TIME OF DEATH I
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 2
<br />24d. TIME PRONOUNCED DEAD
<br />To the bes of my knowledge, death occurred at the time, date and place O
<br />24e. On the basis of examination and/or Investigation, in my opinion death occurred at
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 2
<br />26a . H AS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 2
<br />26b. WAS CONSENT GRANTED?
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print I
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE /� y � 2
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) E
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND.,HUft# I SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKPDEpARTMEOW HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VFrAL\P- EcORDS. t s
<br />DATE OF ISSUANCE
<br />03/10/2014
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />2014 01635
<br />STANLEY S. COOPEk
<br />AS JS.TANT STATE f EEISTRA'fg;
<br />PARTMEN OF HEALTH AIVD
<br />bIAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES, '•.';, •
<br />CERTIFICATE OF DEATH ;
<br />14 01049
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