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1 21010321101V1:13Nfld :A4 pegpenipeleldwoo eq of 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) James Arnold Baxter 2. SEX ' ", Male 3: DATE OF DEATH (Mo., Day, Yr.) April 20, 2011 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH St. Paul, Nebraska 5a. AGE • Last Birthday (Yrs.) 92 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) July 23, 1918 MOS. DAYS ' ?HOURS MINS• 7. SOCIAL SECURITY NUMBER 506 -09 -7194 8a. PLACE OF DEATH HOSPITAL El Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (It not Institution, give street and number) Saint Francis Medical Center ❑ 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 4071 Timberline St. e. APT. NO. r 107 9f. ZIP CODE I 68803 9g. INSIDE CITY LIMITS ® 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 Marcia M Dreher 11. FATHER'S -NAME (First, Middle, Last, Suffix) Thomas Baxter 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Lena Jess 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 02/02/1943 - 12/01/1945 14a. INFORMANT -NAME Marcia M Baxter 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Tracey Dietz 16b. LICENSE NO. 1328 16c. DATE (Mo., Day, Yr.) April 23, 2011 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 10. PART I. Enter the chain of event/I.-diseases, injuries, or compaptlons4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death Days 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) Renal Failure disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) Gram Negative Rod Sepsis any, leading to the puss listed on line 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. Congestive Heart Failure 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 20. IF FEMALE: ❑ Not pregnant within past year P ❑ 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 1:11 Unknown If pregnant within the past year 21a. MANNER OF DEATH El Natural ❑ Homicide ❑ Accident 0 Investigation ❑ Sulfide ❑ 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 220. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE .1' 5 t E 0 Z 23a. DATE OF DEATH (Mo., Day, Yr.) April 20, 2011 4 b' 1 g y EE y` 1 $ & O ~ s 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 2 DATE SIGNED (Mo., Day, Yr.) A•ri129, 2011 23c. TIME OF DEATH 08:05 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD Ii i 8 g 0 9d. To the best of my knowledge, death occurred at the time, date and place 8 and due to the causes) stated. (Signature and Title) 1,2 a Travis S. Hageman, MD 24e. On the basis of examination and/or Investigation, In my opinion death occurred at Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 283. 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 (PHYSICIAN, j Travis S. Hageman, MD, 729 North Custer Avenue, CIAN ASSISTANT, CORONEIF$PHYSICIAN OR COUNTY A Grand Island, Nebraska, 68803 (Type or Print) 1 28a. REGISTRARS SIGNATURE ' A + L ' /t�I(�� rfl�jtaliMl• 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) May 2, 2011 • ' WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF-HEALTH ANDHUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA.D.EPARTMENT Of HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR' V1T,AL "=RECORDS. ' DATE OF ISSUANCE 05/02/2011 LINCOLN, NEBRASKA STATE OF NEBRASKA 201500367 ST/oLey CQOPER ASSISTANT STATE. REGISTRAR 'DEPARTMENT OF HEALTH -AND > HL$ AN SERVICES STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAW SERVECtS CERTIFICATE OF DEATH ' 01401