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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Roland Britton 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) ' May 8, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Taylor, Nebraska 5a. AGE • Last Birthday (Yrs.) 89 5b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) March 6, 1925 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -30 -8374 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) 1011 N. Howard Ave. ❑ 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 1011 N. Howard Ave. e. APT. NO. r 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS M YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown tub. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Elsie Deloris Klapal 11. FATHER'S -NAME (First, Middle, Last, Suffix) Tim Britton 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Hazel Lundy 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or link.) Yes 06/24/1943 - 03/10/1946 14a. INFORMANT -NAME Elsie Deloris Britton 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) May 13, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon 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) I To be completed by: CERTIFIER 18. PART I. Enter the chain of events -- diseases, Injuries, or complicationa4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death Immediate 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) Gunshot Wound To The Head disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially lint conditions, if b) Second Gunshot Wound To The Upper Abdomen Immediate any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to 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 I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 20. IF FEMALE: ❑ Not pregnant within pant year 0 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 ❑ Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ® Suicide ❑ Could ermined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ PedesMan ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES [2] NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) May 8, 2014 22b. TIME OF INJURY 06:00 AM 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) Home 22d. INJURY AT WORK? ❑ YES ®No 22e. DESCRIBE HOW INJURY OCCURRED Apparent self- inflicted gunshot wounds to upper left abdomen and head. 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 1011 N Howard, Grand Island Nebraska 68803 a W II } E o i 23a. DATE OF DEATH (Mo., Day, Yr.) To be completed by CORONER'S PHYSICIAN , or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) May 9, 2014 24b. TIME OF DEATH Approx. 06:00 AM 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH I 24c. PRONOUNCED DEAD (Mo., Day, Yr.) May 8, 2014 24d. TIME PRONOUNCED DEAD 07:10 AM 8 u O 3d. To the best of my knowledge, death occurred at the time, date and place 8 c and due to the cause(s) stated. (Signature and Title) s 24e. On the basis of examination and/or Investigation, In my opinion death occurred al the time, date and place and due to the cause(s) stated. (Signature and Title) Martin Klein, Hall Deputy County Attorney 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? Not Applicable If 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Martin Klein, Hall Deputy County Attomey, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 128a. REGISTRAR'S SIGNATURE� j y il. /� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) May 13, 2014 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA: DEP,ARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE 05/15/2014 STATE OF NEBRASKA 2014 03782 `STANLEY S. COOPER ' ASSISTAJV7#.TATE REGI$TRAk° DEPARTMENT OrHEALTH AND LINCOLN, NEBRASKA HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES , CERTIFICATE OF DEATH 14 02363