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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AT THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASk,4`DEP HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR Js 4 1TAciRe DATE OF ISSUANCE 12/29/2014 LINCOLN, NEBRASKA STATE OF NEBRASKA 201500058 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERW CERTIFICATE OF DEATH ST/;ivf Er s, COOPER ' t 4SSLSTAI,fTe $TAT It}2;qI2 ;, IT CERTIFIES TOF HLALt/ AND 14 06597 1. DECEDENTS -NAME (First, Middle, Last, Suffix) James Brett Campbell • 2. SEX `; Male 3, DATE OF DEATH (Mo., Day, Yr.) ` Debember 5, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH McCook, Nebraska 5a. AGE - Last Birthday (Yrs.) 56 6b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) December 15, 1957 MOS. DAYS HOURS MINE. 7. SOCIAL SECURITY NUMBER 505 -84 -9680 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 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 19e. 3008 Colonial LN APT. NO. 9f. ZIP CODE I 68803 9g. INSIDE CITY LIMITS I 12 YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Marred, but separated ❑ Widowed ❑ Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Tamra Lynne • Sass 11. FATHER'S -NAME (First, Middle, Last, Suffix) Jimmy Francis Campbell 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Janet Walford 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Tamra Lynne Campbell 14b. RELATIONSHIP TO DECEDENT Wife 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.) December 10, 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) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events -- disuses, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death Hours respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Unknown Natural Causes disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death Sequentially list conditions, it b) I any, leading to the cause listed I I on line a. DUE TO, OR AS A CONSEQUENCE OF: ; onset to death Enter the UNDERLYING CAUSE c) I (disease or injury that initiated I 1 the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LAST d) I 1 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 ❑ NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ® NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22e. 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 & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 2' W F 5 e. r Z 23a. DATE OF DEATH (Mo., Day, Yr.) >;' I g k 4 "i K 2 Q g `o 24s. DATE SIGNED (Mo., Day, Yr.) December 22, 2014 2413. TIME OF DEATH Approx. 12:20 PM 23b. DATE SIGNED (Mo., Day, Yr.) 123c. TIME OF DEATH 24e. PRONOUNCED DEAD (Mo., Day, Yr.) December 5, 2014 24d. TIME PRONOUNCED DEAD 12:50 PM O 3d. To the best of my knowledge, death occurred at the time, Bats and plea i w and due to the causala) stated. (Signature and Title) g 2N. 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 Title) Sarah Hinrichs, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN 26a. HAS ORGAN OR TisSUE ❑ YES r • ATION BEEN CONSIDERED? 17 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Sarah Hinrichs, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 p285. REGISTRAR'S SIGNATURE - 2813. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 23, 2014 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AT THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASk,4`DEP HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR Js 4 1TAciRe DATE OF ISSUANCE 12/29/2014 LINCOLN, NEBRASKA STATE OF NEBRASKA 201500058 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERW CERTIFICATE OF DEATH ST/;ivf Er s, COOPER ' t 4SSLSTAI,fTe $TAT It}2;qI2 ;, IT CERTIFIES TOF HLALt/ AND 14 06597