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To Be CompletedNerif ed by: FUNERAL DIRECTOR
<br />1
<br />1. DECEDENTS -VINE (Fkdt, Middle. Lot, Suffix)
<br />Mitchell Harris Stauffer
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Yo.,Day,Yr.)
<br />November 29, 2014
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Deshler, Nebraska
<br />S•. AGE -Last Birthday
<br />(V re.)
<br />93
<br />Sb. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />November 12, 1921
<br />LAOS.
<br />DAYS
<br />HOURS-
<br />MILS
<br />7. SOCIAL SECURITY NUMBER
<br />508-09 -3058
<br />6th PLACE OF DEATH
<br />iliziElial4 0 brv.ti.nt =ram Nursing Home/LTC 0 Hospice Facility
<br />❑ EIVOutpatiot °Decedent's Haas
<br />❑ DOA ❑°")
<br />D. FACILITY -NAME (If not Institution, gY• MINN and number)
<br />St. John's Good Samaritan Center
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Coda)
<br />Keamey 68847
<br />M. COUNTY OF DEATH
<br />Buffalo
<br />9.. RESIDENCE -STATE
<br />Nebraska
<br />M. COIRHTY
<br />Buffalo
<br />9e. CITY OR TOWN
<br />Keamey
<br />9d. STREET AND NUMBER
<br />808 West 24th Street
<br />lie. APT. N0.
<br />I
<br />M. ZIP CODE
<br />( 68845
<br />9y NSW STY UNITS
<br />® Vas 0 No
<br />10x. MARITAL STATUS AT TINE OF DEATH ®Ma+fed ()Never
<br />0 Married, but operated 0 Widowed 0 Divorced 0 Urdutown
<br />101. NAME or SPOUSE (First, Middle, Last SWIM) B 044 Sh'e -med.n twas.
<br />Helen Winter
<br />11. FATHER'S•NA1dE (First, Middb, Last, Suffix)
<br />Amos Ezra Stauffer
<br />12. MOTHER'S -NAME (First, Middle. Malden Summer)
<br />Beulah Mitchell
<br />13. EVER IN U.S. ARMED FORCES? Glue dates of service H Yea
<br />(Yes, No or wb•) Yes 09/29/1942- 12/27/1914
<br />14e. I FORMANT -NAME
<br />Robin Stauffer
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />16. METHOD OF DISPOSMON
<br />['Burial Donation
<br />®Cwnwda, ❑Em.ab,esn
<br />❑grew, Ooeattsvwh)
<br />16th EMBALMER-SIGNATURE
<br />Not Embalmed
<br />10b. LKJENBE NO.
<br />164. DATE (Mo., Gay, Yr.)
<br />December 1, 2014
<br />161. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />Josten Cremation Service Keamey Nebraska
<br />17e. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City Or Town, State)
<br />O'Brien- Straatmann- Redinger Funeral Home, 4115 Avenue N, PO Box 2344, Keamey, Nebraska
<br />17b. no Code
<br />68847
<br />1 { l� .. % - To Be Completed by: CERTIFIER
<br />CAUSE.OF DEATH (See Instructions and examples)
<br />N. PNR 1. Dater M. gibakuargigi • *ram, Wmis.. e aeaplledlo •dadaeay DO NOY ear tmm,a rode mob at colic snot APPROXIMATE INTERVAL
<br />memory anon or ventricular 'Wiliam without tlwrN9 Oa etiology. DO NOT ABBREVIATE. Saw only tree our m ■ t Ind Walton* Abus a noea.e2.
<br />MEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Fist
<br />Osease in) "Bong' a) Congestive Heart Failure Unknown
<br />DUE TO, OR AS A CONSEQUENCE OF: I onot to death
<br />t
<br />Sequentially list conditions, ti I
<br />MY. laerthgtol.ce** listed b) Chronic Obstructive Pulmonary Disease, Atrial Fibrillation
<br />on Linea DUE TO, OR AS A CONBEOUENCE OF: ; onset to death
<br />Enter the UNDERLYING CAUSE c) t
<br />Initiat(disease
<br />(disease Injury
<br />or that
<br />Bat eueMs rseuPJng In deoh) DUE TO, OR AS A CONSEQUENCE OF: i onset to death
<br />LAST
<br />t
<br />,
<br />d) I
<br />16. PART L OTHER SKYdRCANT CONDITIONS-Condition contributing to the death but not routing in the underlying oauo given In PART L
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />I ® YES ❑ NO
<br />20. IF FEMALE:
<br />ONO pregnant within past year
<br />❑Pregnant at time of dead,
<br />❑Not pregnant, but pregnant within n 42 days of death
<br />❑pat pregnant, but prepam 43 days to 1 year before death
<br />❑unima.n I pregnant within the past yell
<br />219. MANNER OF DEATH
<br />at NSttm l 0 Hanks.
<br />❑ Accident 0 Pending Investigation
<br />❑ Suicide ❑ Could not determined
<br />21b. IF TRANSPORTATION WJ
<br />0 Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />0 OFF (Sp.cIty)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES also
<br />Y
<br />ltd. WERE PLETE CAAUSE USE O OF AVAILABLE
<br />TO COMtM.E7E R OEATHI
<br />❑ YES ❑ NO
<br />22.. DATE OF INJURY (Mo., Day, Yr.)
<br />f 22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -At home, fanm• stmt, factory, office building, construction sib, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />0 YES ❑ NO
<br />( 22.. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET a NUMBER, APT. N0. CITY/TOWN STATE ZIP CODE
<br />CC
<br />Vi
<br />28x. DATE OF DEATH (Mo., Day, Yr.)
<br />.41
<br />P O
<br />=k
<br />54
<br />24th DATE SIGNED (Mo., Day, Yr.)
<br />12 -02 -14
<br />24b. TIME OF DEATH
<br />7:50 pen
<br />22b. DATE S EKED (Mo., Day, Yr.)
<br />230. TINE OF DEATH
<br />m
<br />24c. PRONOUNCED DEAD Mo., Day, Yr.)
<br />11 -29 -14
<br />24d. TIME PRONOUNCED DEAD
<br />7 :50 p
<br />: 1 Md. To the beet of MY MMTNIN M, death occurred et Be Stu, deb.rd place
<br />B 3 and due to tie cau.s(a) stated. (Signature ad Title)
<br />j
<br />GI b Fi 4 f s►r
<br />r
<br />25 DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ❑ NO ❑PROBABLY IN UNKNOWN
<br />26x. HAS ORGAN OR TISSUE DONATION A.
<br />❑ YES ® NO
<br />2613 W - ) r: 1 ANTED?
<br />Net ApplicM I. N NO ❑ YES 13 NO C
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Prim)
<br />Nandi J. Atny,,Deputy Buffalo County Attorney, PO Box 67, Kearney NE 68848
<br />P 26x. REGISTRAR'S SIGNATURE
<br />26b. DATE FILED B YEC 4 2 x, ` , Yr.
<br />DATE OF ISSUANCE
<br />12/08/2014
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBR3SKA
<br />201408143
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER15q ' ) 1
<br />f�� RTtt�lt_ATP AF r]FATH
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEATH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA,SKA•tJ P tkTSME(VT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOa'VIT�g4,l3ECQR
<br />d. 0
<br />, ';'STANLEY S..COQPER '
<br />ASSISTACVT_ REGISTf AP1
<br />DEPARTME T HEALTH AND?
<br />KfJMAN SE t EE "
<br />•
<br />109
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