|
To Be Completed/Verified by: FUNERAL DIRECTOR I
<br />1. DECEDENT'S-NAME (First, Middle. Last, BuNfix)
<br />Clayton Leon Kauffman
<br />2. SEX
<br />Male
<br />A DAYE'OPOEAAAI (Mo.,Ds,Yr.)
<br />September 5, 7014
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Marquette, Nebraska
<br />ICI AGE -Last Birthday
<br />(Tn.)
<br />75
<br />Sb. UNDER 1 YEAR
<br />Sc. UNDER I DAY
<br />IL DATE OF BIRTH Oda, Day, Yr.). ,i'
<br />April 5, 1939
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINE.
<br />1. SOCIAL SECURITY NUMBER
<br />50 8-4 4-54 57
<br />ICI PLACE OR'DEATH
<br />1112WITA.: gl 'madam am= Nursing Horne/LTC ❑ Hospee FaaSLy
<br />0 ER/Outpatient ❑ Decedent's Home
<br />❑ DOA ❑
<br />Mt. FACI.m•NAME (If not Institution, give street ape number)
<br />Veterans Affairs Medical Center
<br />Sc. CITY OR TOWN OF DEATH (Include 22p Code)
<br />Grand Island 68803
<br />Ed. COUNTY OF DEATH
<br />Hall
<br />Es. RESIDENCE-STATE
<br />Nebraska
<br />w. COUNTY
<br />Hall
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />Ed. STREET AND NUMBER
<br />1315 Stagecoach Road
<br />ea. APT. NO.
<br />M. VP CODE
<br />68801
<br />9g. INSIDE CITY UNITS
<br />® Yea 0 No
<br />10a. MARITAL STATUS AT TIME OF DEATH ®Mated ❑ Never Married
<br />❑ Minted, but ewaated ❑ Widowed ❑ Divorced ❑ U"Imown
<br />100. NAME OF SPOUSE (First, Middle. Last, Suffix) B wife, SIw Malden mum
<br />Nancy Ann McHargue
<br />11. FATHERS -NAME (Find, Middle, Last, Suffix)
<br />Wesley Blaine Kauffman
<br />12. MOTHER'S -NAME (Perm, WWI., Malden Surname)
<br />Helga Marie Andersen
<br />13. EVER IN U.S. ARMED FORCES? dew dates of service *Yes.
<br />(Yes, No, or Usk.) Yes 10/04/1955. 10/03/1961
<br />14a. INFORMANT -NAME
<br />Nancy Ann Kauffman
<br />14b, RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSmON
<br />IZEturiel ClOomation
<br />❑cnnaen 0Otteawe.et
<br />❑symovet Ooeextsa.thl
<br />16a. EMBALMER TURE �
<br />� T""a•+ -
<br />IN. LICENSE NO.
<br />/3 7 3
<br />150. DATE (Mo., Day, Yr.)
<br />September 9, 2014
<br />15d. CEMETE EMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />Aurora Cemetery Aurora Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS Meat, City or Town. State)
<br />Higby McQuiston Mortuary, Inc., 1404 L Street, PO Box 204, Aurora, Nebraska
<br />17b. Zip Cods
<br />88818
<br />r
<br />To Be Completed by: CERTIFIER
<br />CAUSE OF DEATH (See Instructions and examples)
<br />it. PART L Eder thy sOIRLDL tale - dNrwa, tµM., of ca.pxaaew dot directly MON MO d&MA DO NOT mtora mdnal ware ass as stylia me* APPROXIMATE INTERVAL
<br />eaaraay anon, or v.nnkaernOWMlan without Mawtna the Arta.. DO NOT ABEMBIATE. Eller only der anno in • let'. Add additional Wide It *army.
<br />IMMEDIATE CAUSE: anaat to death
<br />dimes IMMEDIATE condition resulting a) A ►yi Y v i Q o P H ( c L. + k • 7 F it a c . CC L e 1 ( 0 s t y
<br />M death)
<br />DUE TO. OR AS A CONSEQUENCE OF: onset to death
<br />Spuedially list conditions, I b)
<br />any, leading to dm cause listed - ?
<br />on Une a. DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Ender the UNDERLYING CAUSE c)
<br />(disease at Injury that Initiated
<br />the awn. restting M d eath) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST
<br />d)
<br />It PART IL OTHER SIGNIFICANT CONDMONS.CondiSono conbibutIng to the death but not resulting M the underlying taws glean In PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES B NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />❑Pregnant at dam of death
<br />❑Not pregn but POMPOM wNbln 42 days of death h
<br />a t.
<br />ONot poignant, but pregnant 43 days to 1 year before death
<br />❑Unbnown I pregnant within the past year
<br />212. MANNER OF DEATH
<br />® NoWnl ❑ Homicide
<br />❑ Accident ❑ Pandits Investigation
<br />❑ Suicide ❑ Could not be determined
<br />rib. IF TRANSPORTATION INJURY
<br />❑ DiMMODWatar
<br />❑ Passenger
<br />0
<br />❑ Other (Specify)
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />❑ YES 51 NO
<br />AUTOPSY
<br />TO COMPLEG FINDINGS OF AVAILABLE
<br />DEATH
<br />❑ YES JfO
<br />22a. DATE OF INJURY (Mo.. Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY-At home, fans, street, factory. *Rice budding, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY • STREET & NUMBER APT. NO. CmROWN STATE 23P CODE
<br />44 $'
<br />$
<br />7.3s DATE OF DEATH (Mo., Day, Yr.)
<br />t= Pi6Ynn 3E R 5. �.v14
<br />$ 3
<br /><
<br />$
<br />$ il
<br />to g
<br />V S
<br />24B DATE SIGNED (Mo., Day. Yr.)
<br />"'
<br />24b. TIME OF DEATH
<br />RT ,
<br />23 DATE SIGNED (Mo., Day, Yr.)
<br />dPP' q a4►`F
<br />230. TIME OF DEATH
<br />05;01 Am
<br />240. PRONOUNCED DEAD (Mo., ay, Yr.)
<br />24d. TRW T PRONOUNCED DEAD
<br />m
<br />230. To the bast of m .., ^. :. dMh occurred at Bur dm, date and place
<br />e e • ( :..; , and Title)
<br />ml)
<br />24e. On the basis of exanbrwon a °for investigation. M my opinion death occurred
<br />at the tine, date and puce and due to the cause(*) stud. (Signature and Thu)
<br />!"
<br />25. DID TOBACCO •- - - TE TO THE 0 r TM? '• ...'
<br />D YES NO ... ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES I3 NO
<br />2Eb. WAS CONSENT GRANTED?
<br />Not Applicably/ If 250 Is NO ❑ YES Tit NO
<br />27. NAME. TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />i 4RK a AtJULEt *JR In. iyt,V'Amc, )101lv,8(tu) Lt.1LL IsL ,NC W03
<br />P
<br />2Ea. REGISTRAR'S SIGNATURE
<br />Asbriet r,,
<br />ZSb. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />SEP 1 2014
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEP.,ARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAC"RsCQRDS. '
<br />; ( '
<br />DATE OF ISSUANCE
<br />09/16/2014
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />201407722
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIdEIL ' '! 26
<br />CERTIFICATE_OF DEATH `z .
<br />'rw
<br />STAWI EY S, COOPER l/ •• „
<br />4SSSIANT STATE-REGISTRAR °
<br />DfRAR:TMENr 1F 15ALTH AND is
<br />HUMAN sERVIez
<br />
|