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1. DECEDENTS -NAME (First, Middle, Last, Suffix) Henry Alfred -Tedd- Kincheloe 2. SEX Male To„Dey,Yr.) ; k IRATE OF DEAH M April 20, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Lexington, Nebraska 5a. AGE -Last Birthday (Yrs.) 87 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) October 12, 1924 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -12 -4661 8a. PLACE OF DEATH )1OSPITAL, ❑ Inpatient OT ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient - ® Decedent's Home ❑ �+ ❑ Other(Specify) 8b. FACILITY -NAME (If not Institution, give street and number) 2803 W. Forrest St. 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2803 W. Forrest St. 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS E Yes ❑ No 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Dorothy Ottman 11. FATHER'S -NAME (First, Middle, Last, Suffix) • John Henry Kincheloe 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ida Colb 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 05/17/1943- 07/26/1945 14a. INFORMANT -NAME Dorothy Kincheloe 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION El Burial ❑Donation ❑Cremation ❑Emombmenl ❑Removal ❑Othegapeeity) 16a. EM ER- SIGNATURE 0T �'�° 16b. LICENSE NO. 7 16c. DATE (Mo., Day, Yr.) April 25, 2012 16d. CEMETERY, CREMAT Y OR OTHER LOCATION CITY/TOWN STATE Westlawn Memorial Park Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 • CAUSE OF DEATH (See instructions and examples) 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 respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Inc l. Add eddhlonat line. R necessar'. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final \,, disease or condition resulting a) C R4 d 1 0,z C t \ • v ‘JLc1 den DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially 11st conditions, If b) \ any, leading to the cause listed �� AX Q �C1Gr C n ‘ \7 �, DS A online a. DUE TO, OR AS A CONSEQUENCE OF: onc�etto death Enter the UNDERLYING CAUSE c) (disease or Injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting In the underlying cause given In PART!. ••�` . Q A 1 ek. V � 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES Eit NO 20. IF FEMALE: ❑ Not pregnant within past year 13 Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ['Unknown if pregnant within the past year 21a. MANNER OF DEATH �, ;IVatural ❑ Homicide � Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator i] Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES a NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? ❑ YES NO NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? DYES X NO -_ 22e. DESCRIBE HOW INJURY OCCURRED 220. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE - ZIP CODE LL li 3 a 2 V 3 w r 2 23a. DATE OF DEATH (Mo., Day, Yr.) App a0, sole Z - T a a _ z d } 0 orc a 0 W z 2 O O 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH m 23 DATE SIGNED (Mo., Day, Yr.) P pi 30. aOla 23c. TIME OF DEATH t i . .Q Am 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD m 23d. - To the best of my knowledge, death occurred at the time, date and place and du to the cause(s) stated. ( ure and Title) 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ' UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES Ejt NO 26b. WAS CONSENT GRANTED? Not Applicable If 28a Is NO ❑ YES [$ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) 1 CAC1 0. C.cpcil cl 1c1 C1 "ft t. Gaol N e)cood■r(e. \\ 6Kanci Z.,. via N1:brc c (.4► $8!):1 28a. REGISTRAR'S SIGNATURE /dad*. 11. 6012ft• 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) - MAY 1 2012 . I WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH - 21N !!IUM,A�V S'EF VICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKAE• AR�7T`1'`ENT OF`!lEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR.V'ITAL EG'? QS ' • ' DATE OF ISSUANCE S :ANLEY S‘`EOOPF7J? w ASS3"STAN7 §•7'34 Et. REGISTRAR DEPARTMENT OF HEALTH AND , LINCOLN, NEBRASKA HUpfA)1bSERVJCES - k :,• STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVfc�ES i. y ' 12 0'2 3 ; 3 1 : 4 Amended May 16, 2012 CERTIFICATE OF DEATH • MAY 162012 20140 STATE OF NEBRASKA