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To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Frederick L Kinghorn 2. SEX 1 ' " ; . Male t . ;$. DATE OF OE"ATH(Mo., Day, Yr.) , -,ul'y 7,'2Q 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Crab Orchard, Nebraska 5a. AGE - Last Birthday (Yrs.) 84 6b. UNDER 1 YEAR 5c. UNDER 1 DAY ' '8. Sim O BIRTH (Mo., Day, Yr.) January 11,1930 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 521 -38 -1856 8b. FACILITY -NAME (If not Institution, give street and number) A Golden Living Center - Park Place, Grand Island 8a. PLACE OF DEATH HOSPITAL, ❑ Inpatient OTHER ® Nursing Home/LTC ❑ 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 2765 St. Patrick Av e. APT. NO. r 9f. ZIP CODE I 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Patricia Hanlon 11. FATHER'S -NAME (First, Middle, Last, Suffix) James Kinghorn 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Sarah McCoy 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Patricia Kinghorn 14b. RELATIONSHIP TO DECEDENT Spouse 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.) July 7, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (Seeinstructions and examples) To be completed by: CERTIFIER IS. 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: IMMEDIATE CAUSE (Final a) Metastatic Melanoma disease or condition resulting onset to death Months in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b) I any, leading to the cause listed 1 I line on a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) I (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LAST d) 1 t 1 18. PART IL OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the d but not resulting In the underlying cause given in PART I. Alzheimers Dementia 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 El 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 ❑coin 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 construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET 8, NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 3• W w r Q. W z 23a. DATE OF DEATH (Mo., Day, Yr.) July 7, 2014 To be completed by CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) July 7, 2014 1 23c. TIME OF DEATH 01:07 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD u < O 3d. To the best of my knowledge, death occurred at the time, date and place 2 c and due to the cause(s) stated. (Signature and Title) ~ f Travis S. Hageman, MD 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 TRIO 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES El NO 26b. WAS CONSENT GRANTED? Not Applicable If 26e Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE A - ( 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) July 10, 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 NEBRASKXSEI pF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RKDS g c DATE OF ISSUANCE 07/14/2014 STATE OF NEBRASKA 201404557 STANLEY Y'S COOPER ASSISTANT ,STATE ,REEISTRA`R' ' e D PFR•TMF VT PE HS4I472,H AND LINCOLN, NEBRASKA HUMAN SERVICES STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SE(IVIt&S-. ✓ CERTIFICATE OF DEATH r s • 11 r. 14 03383