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To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENT'S •NAME (First, Middle, Last, Suffbc) Jack Ellis Sample 2. SEX a Male 3. D,i4TE9F DU" (Mo., Day, Yr.) Iv� 2014. 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH St. Edward, Nebraska 5a. AGE • Last Birthday (Yrs.) 77 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) October 12,1936 MIS. I DAYS HOURS MINE. 7. SOCIAL SECURITY NUMBER 320 -34 -8937 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedents 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 9e. CITY OR TOWN Grand Island STREET AND NUMBER 13 Via Como re. e. APT. NO. 9f. ZIP CODE I 68803 9g. INSIDE CITY LIMITS I ® 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 Linda Morris 11. FATHER'S -NAME (First, Middle, Last, Suffix) Ted Sample 12. MOTHER'S -NAME (First, Middle, Malden Surname) Iva Ellis 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 08/16/1954- 04/20/1973 14a. INFORMANT -NAME Linda Sample 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMERSIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) May 30, 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) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER I 13. 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 line. Add additional lines if necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final a) Acute Renal Failure 16 Days disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: . onset to death Sequentially flat conditions, If b) Hypotensive Shock 16 Days any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Septic Shock 16 Days (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•Conditlons contributing to the death but not resulting in the underlying cause given In PART I. Congestive Heart Failure And Cardiomyopathy 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 0 N 20. IF FEMALE: ❑ Not pregnant within past year ❑ 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 U pregnant within the past year 21a. MANNER OF DEATH ® 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? DYES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE pw I a Y Euz 23a. DATE OF DEATH (Mo., Day, Yr.) May 30,2014 3'ii I i' F Y E a.< z � 8 0 2 z G ~ 8 s 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) June5,2014 23c. TIME OF DEATH I 07:30 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 < 0 3d. To the best of my knowledge, death occurred at the time, date and place 2 and due to the cause(s) stated. (Signature and Title) Larry L. Hansen, MD 24e. On the basis of examination and/or Investigation, In my opinion death occurred at s) stated. (Signature and TI MM the time, date and place and due to the cause(s) IN) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 263. HAS ORGAN OR ❑ YES ISSUE r • Ea NO ATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Larry L. Hansen, MD, 3016 West Faidley, Grand Island, Nebraska, .:: e 1 2 8a. REGISTRAR'S SIGNATURE f A. f � 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) June 6, 2014 T CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA (t EP RTP Pies OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR b'ITAL, CORES. , - DATE OF ISSUANCE 06/06/2014 STATE OF NEBRASKA ST iN1.EY3.. COOPER 61SSI,5TA44 �, TAT GIS R T•F R ,DO,4'RT/N�E7Utb¢� 1TH All p LINCOLN, NEBRASKA PUN AN SERVICES - STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVtaiS. �•, ' CERTIFICATE OF DEATH 2 01404519 14 02777