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CER
<br />T IFICATE O DEATH
<br />1. DECEDENT'S -NAME (First, Middle, Last, SuffiX) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />Philip Byron Hazen Male Jupe;B; 2006
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday 5b. UNDER 1 YEAR 5o, UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yrs.) MOS. DAYS HOURS MINS. •
<br />Remsen, Iowa 83 September 15, 1922
<br />7. SOCIAL SECURITY NUMBER • 8a. PLACE OF DEATH
<br />480-44 -7469 HOSPI AL: l Inpatient OTHER: ❑ NursingHome/LTC ❑ Hospice Fadlity
<br />� Sb. FACILITY -NAME (If not institution, give street and number) ❑ ER/Outpatient ❑ Decedent's Home
<br />O
<br />U
<br />t2 Saint Francis Medical Center ❑ DCM ❑ Other (Specify)
<br />Bc. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />Z . 9a. RESIDENCE -STATE 9b.COUNTY 9c. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />19e. APT. NO I Et. ZIP CODE 9g. INSIDE CITY LIMITS
<br />9d. STREET AND NUMBER GII YES ❑ NO
<br />1204 W. Louise 68801
<br />10a. MARITAL STATUS AT TIME OF DEATH ( l Married ❑ Never Married 10b. NAME OF SPOUSE (First. Middle, Last, Suffix) If wife, give maiden name.
<br />d
<br />d
<br />a ❑ Marned, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />o Arlene Feddersen
<br />O Louis T Hazen 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Maiden Surname)
<br />n Deborah Means
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. 14a. INFORMANT -NAME 14b. RELATIONSHIP TO DECEDENT
<br />(Yes, no, orunk.) Yes 03/31/1944 - 02/07/1946 Arlene Hazen _ Wife
<br />15. METHOD OF DISPOSITION 16a. EMQALMER•SITI} r
<br />16b. LICENSE NO. 16c. DATE (Mo., Day, Yr. )
<br />® Burial ❑ Donation � tT 1 328 June 12, 2006
<br />❑ Cremation ❑ Entombment 16d. CEMETE( CREMATORY O OTHER LOCATION
<br />CITY I TOWN STATE
<br />❑ Removal ❑ Other (Specify) Grand Island Nebraska
<br />Westlawn Memorial Park Cemetery
<br />17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City or Town, State) G ip Co
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, N 17b. Zip Code
<br />Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />' 16. PART 1. Enter 'he chain o! events diseases, In;udes. or complications - -that directly caused the death. DO NOT enter termi events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVI ATE. Enter only one cause on a line. Add additional lines 11 necessary.
<br />onset to death
<br />IMMEDIATEC USE:
<br />h
<br />IMMHDIATECAUSE(Fhal I onset to death
<br />disease or condition resulting DUE TO, OR ASA CONSEQUENCE OF:
<br />In death) 1
<br />Sequentially list conditions, If (b) E
<br />any, leading to the cause listed DUE TO, OR ASA CONSEQUENCE OF: RECEIVED I onset to death
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(dlseese or In)ury that Initialed (c) - - JUL 032006 i onset to death
<br />the events resulting h V death) DUE
<br />LAST
<br />(d) A a`
<br />18. PART IL OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but net resulting In the un Cyleg a n m PART I. 19. WAS MEDICAL EXAMINER
<br />OR CORONER 0ONy4rEDi
<br />❑ YES Ly�NO
<br />W 20. IF FEMALE: 21a.MANMEROFDEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PER RMED?
<br />C N atural ❑ Homicide ❑ Driver /Operator
<br />❑
<br />r '- ❑ Not pregnant within past year ❑ YES NO
<br />Passenger
<br />❑ Pregnant at time of death ❑ Accident❑ Pending Investigation ❑Pedestrian 21 d: WERE AUTOPSY FINDINGS A TO
<br />0 Not pregnant, but pregnant within 42 days of death ❑Suicide ❑ Could not be determined 0 Other (Spedly)
<br />d ❑ Not pregnant, but pregnant 43 days to 1 yearbefore death COMPLETE CAUSE OF DEATH?
<br />I.' ❑ YES ❑ NO
<br />❑ Unknown if pregnant within the past year
<br />U 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY home, farm, street, factory, office building, constn. ^.lino site, etc. (Specify)
<br />E
<br />m
<br />no
<br />I� 22d. INJURY AT WORK? 22e. DE HOW INJURY OCCURRED
<br />❑ YES ❑ NO
<br />eTaTC ZIP CODE
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEC TION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />1 4 2006
<br />201403710 ASSISTANT ST TE_REGISTRAAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINAIVOE -AND SUP PO - -6520
<br />F
<br />DATE OF ISSUANCE
<br />JUN
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
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<br />CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 8, 2006
<br />23b. DAT SIGNED (Mo., Day,Yr.)
<br />2006
<br />sl of my knowledge,
<br />auseOj stat
<br />23c.TIME OF DEATH
<br />8:28 a
<br />1
<br />28a. REGISTRARS SIGNATURE
<br />ath occurred at the time, date and place
<br />(Signature and Title)
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<br />24a. DATE SIGNED (Mo., Day,Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />26a. HAS ORGAN OR TISSUE D�O. ATION BEEN CONSIDERED?
<br />❑ YES NO
<br />25. DID Tr -BAC • USE CONTRIBUTE TO THE o 7 ?
<br />❑ YES �NO ❑ PROBABLY ❑ UNKNOWN
<br />27. NAME. TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Pnnt)
<br />A. .►
<br />24b. TIME OF DEATH
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<br />24d. TIME PRONOUNCED DEAD
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<br />24e. On time, date and nd place and due to the Investigation, In
<br />stated. my (Signature Title )
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑ YES ❑ NO
<br />John A. Wagoner M.D., 800 Alpha, Grand Island, NebrFska
<br />68803
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />JUN 1 3 206
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEC TION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />1 4 2006
<br />201403710 ASSISTANT ST TE_REGISTRAAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINAIVOE -AND SUP PO - -6520
<br />F
<br />DATE OF ISSUANCE
<br />JUN
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
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<br />Tay
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<br />CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 8, 2006
<br />23b. DAT SIGNED (Mo., Day,Yr.)
<br />2006
<br />sl of my knowledge,
<br />auseOj stat
<br />23c.TIME OF DEATH
<br />8:28 a
<br />1
<br />28a. REGISTRARS SIGNATURE
<br />ath occurred at the time, date and place
<br />(Signature and Title)
<br />m
<br />ao
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<br />E Z -0
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<br />omo
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<br />24a. DATE SIGNED (Mo., Day,Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />26a. HAS ORGAN OR TISSUE D�O. ATION BEEN CONSIDERED?
<br />❑ YES NO
<br />25. DID Tr -BAC • USE CONTRIBUTE TO THE o 7 ?
<br />❑ YES �NO ❑ PROBABLY ❑ UNKNOWN
<br />27. NAME. TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Pnnt)
<br />A. .►
<br />24b. TIME OF DEATH
<br />m
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />24e. On time, date and nd place and due to the Investigation, In
<br />stated. my (Signature Title )
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑ YES ❑ NO
<br />John A. Wagoner M.D., 800 Alpha, Grand Island, NebrFska
<br />68803
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />JUN 1 3 206
<br />
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