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To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Wilbur Louis Salmon 2. SEX ' ' t ' Male " ; I "3.t1.TE OF DEATH (Mo., Day, Yr.) found January 5, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Hamilton County, Nebraska 5a. AGE • Last Birthday (Yrs.) 89 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.) June 15, 1923 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507-48 -2792 8b. FACILITY -NAME (If not Institution, give street and number) 3020 North Webb Road 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 Nebraska COUNTY I Hall 9c. CITY OR TOWN I Grand Island 3020 North Webb Road re. APT. NO. 9f. ZIP CODE f 68803 9g. INSIDE CITY LIMITS I IA 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 Arlene Eckerson 11. FATHER'S -NAME (First, Middle, Last, Suffix) Peter C Salmon 12. MOTHER'S -NAME (First, Middle, Malden Surname) Edna Ross 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Arlene Salmon 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION Q Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Kenny Howland 16b. LICENSE NO. 1373 16c. DATE (Mo., Day, Yr.) January 9, 2013 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE Aurora Cemetery Aurora Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Higby McQuiston Mortuary, nc., 1404 L Street, PO Box 204, Aurora, Nebraska 17b. Zip Code 68818 CAUSE OF DEATH (See Instructions and examples) To be completed by: CERTIFIER 11I. 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 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) Undetermined Natural Causes disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: - onset to death Sequentially list conditions, if b) any, leading to the cause listed Tine on 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 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 if 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 El 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 & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE W '' J r, Z 23a. DATE OF DEATH (Mo., Day, Yr.) S g W 7 $ p U t 24a. DATE SIGNED (Mo., Day, Yr.) January 9, 2013 24b. TIME OF DEATH Approx. 12:01 AM 23b. DATE SIGNED (Mo., Day, Yr.) 123c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) January 5, 2013 24d. TIME PRONOUNCED DEAD 10:30 AM 0 9d. To the best of my knowledge, death occurred at the time, date and place E and due to the causes) stated. (Signature and Title) 24e. On the basis date of a examination and/or investigation, in my opinion death occurred at the time, and place and due to the causes) stated. (Signature and Title) Dave Medlin, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Dave Medlin, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 2k. REGISTRAR'S SIGNATURE A j /a 285. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I January 10, 2013 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SRVICFS, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBWKA„peRARINE,NT OF HEA1 TH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOltiriVt R QS. k 3 DATE OF ISSUANCE 01/15/2013 LINCOLN, NEBRASKA 201406251 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SEES CERTIFICATE OF DEATH COOPER ASSISTANT STAT,R DEI ZRTM t^,UMA(V-S 13 00100