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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Stanley E Alexander 2. SEX Male 4iD,ATE DeAlti (Mo., Day, Yr.) N . Septe4Dber2.1, 2010 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Hastings, Nebraska 5a. AGE • Last Birthday (Yrs.) 76 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6.DATE OF"6JRTH (Mo., Day, Yr.) October 6, 1933 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -36 -3002 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home /LTC Er Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 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 6481 S Engleman Road 9e. APT. NO. 9f. ZIP CODE 68803 eg. INSIDE CITY LIMITS ® 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 Phyliss A DeVries 11. FATHER'S -NAME (First, Middle, Last, Suffix) MC Alexander 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Anna Schwartzkopf 13. EVER IN U.S. ARMED FORCES? Give dates of service 11 Yes. (Yes, No, or Unk.) Yes 07/01/1953- 06/01/1955 14a. INFORMANT -NAME Mark Alexander 14b. RELATIONSHIP TO DECEDENT Son 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE James M. McLaughlin 16b. LICENSE NO. 951 16c. DATE (Mo., Day, Yr.) September 24, 2010 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Parkview Cemetery Hastings Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livingston - Butler - Volland Funeral Home, 1225 N. Elm, Hastings, Nebraska 17b. Zip Code 68901 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 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 onset to death Months respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Acute Renal Failure disease or condition resulting I n death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list condition, if b) VRE And MRSA Sepsis Days any, leading to the cause listed on tine a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Hypertension Years (disease or injury that Initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) Diabetes Years 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Obesity Hypoventilation Syndrome, Osteoarthritis 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death P dea ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 49 days to 1 year before death ❑ Unknown If pregnant within the past year 21a. MANNER OF DEATH ID Natural ❑ Homicide ❑Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 3' w I F } E ii z 23a. DATE OF DEATH (Mo., Day, Yr.) September 21, 2010 r B g W 1 s k E h < 0 u, O z p '" u o 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) September 22, 2010 23c. TIME OF DEATH 10:48 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 'a; 3d. To the best of my knowledge, death occurred at the time, date and place o c and due to the cause(s) stated. (Signature and Title) ~ 2 Kimberly A. Mickels, MD 24e. On the basis of examination and /or investigation, in my opinion death occurred at the ti 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 ® NO 26b. WAS CONSENT GRANTED? I Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER ( PHYSICIAN, Kimberly A. Mickels, MD, 729 North Custer Avenue, HYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY A Grand Island, Nebraska, 68803 TORNEY) (Type or Print) 28a. REGISTRAR'S SIGNATURE// A- 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I September 22, 2010 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND, idUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE. WITH THE NEBRASKA FDEP .F HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL R COkDS. I DATE OF ISSUANCE 09/24/2010 LINCOLN, NEBRASKA STATE OF NEBRASKA 201403003 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES=- • , . CERTIFICATE OF DEATH STA! EY S COOPER AS ISTANTISTATE REGISTRAR "' /' DEPARTMENTOF HEALTH AND:: HUMAN SERVICES 10 02679