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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Lincoln Chin Wing 2. Se/1 '. / // i , ' Male « :, Y 1 3 DAL►, DEATH (Mo.; Dat(, Yr.) ' M ayj 4 , 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH North Platte, Nebraska 5a. AGE - Last Birthday (Yrs.) 77 6b. UNDER 1 YEAR 5c. UNDER 1 DAY `' "6.bATE OF BIRTH (Mo., Day, Yr.) August 8, 1935 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -36 -7524 8b. FACILITY -NAME (If not Institution, give street and number) 127 Arapahoe 8a. PLACE OF DEATH HOSPITAI ['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 127 Arapahoe e. APT. NO. r 8f. 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 Rosa Ramirez 11. FATHER'S -NAME (First, Middle, Last, Suffix) Chin Wing 12. MOTHER'S -NAME (First, Middle, Maiden Sumame) Lily Lee 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 03/22/1955 - 03/21/1963 14a. INFORMANT -NAME Rosa Wing 14b. RELATIONSHIP TO DECEDENT Spouse 16. 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 15, 2013 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) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska for Central Nebraska Cremation & Mortuary Service 609 Front Street, PO Box 280, Gibbon, Nebraska 17b. Zip Code 68801 68840 CAUS OF DEATH (See instructions and examples) To be completed by: CERTIFIER I 15. PART 1. Enter the chain of events - diseases, injuries, or complicationsehat directly caused the death. DO NOT enter terminal events such as cardiac arrest, r 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) Respiratory Failure disease or condition resulting onset to death In) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b) Lung Mass, Presumed Cancer 1 19 Months any, leading to the cause listed I 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) I (disease or Injury that Initiated 1 the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) 1 1 I 18. PART II.OTHER SIGNIFICANT CONDITIONS - Conditions contrlbutlng to the death but not resulting in the underlying cause given in PART 1. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? DYES ®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 El 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? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) a W May 14, 2013 Ali k r o r+ o ' w g z R, 12 a 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH F 23b. DATE SIGNED (Mo., Day, Yr.) t§i May 15, 2013 23c. TIME OF DEATH I 01:45 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3d To I best of my knowledge, death occurred at the time, date and place B , o G and due to the cause(a) stated. (Signature and Title) 2 Isaac J. Berg, 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 causes) stated. (Signature and Tkle) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 126a. ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 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 Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803 1 285. REGISTRAR'S SIGNATURE i d - .O { 1�1f /V 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) May 16, 2013 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH A� OMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAERWA�P OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITALI RECOkP 1 ' T IlJO . ST4NLEY S. ` ' • A 5IS T T j!' i$ I PAR t ALTI ,2N Hql yAN SERVICES r ^t STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN<SE(1I0* I c :4 13102139 CERTIFICATE OF DEATH ' ., OH \r-',-,‘•• ,t' -° r DATE OF ISSUANCE 11/07/2014 LINCOLN, NEBRASKA STATE OF NEBRASKA 201407501