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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) John Robert Curl 2. SEXt, t Male .' '. , 3. DATE OF DEATH (Mo., Day, Yr.) .,Fgbrilary 1, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Pocatello, Idaho 5a. AGE - Last Birthday (Yrs.) 72 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.) August 7, 1942 MOS. DAYS HOURS `MINS. 7. SOCIAL SECURITY NUMBER 518-48 -6981 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 1930 North Custer Avenue 9e. APT. NO. 9f. ZIP CODE 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 11. FATHER'S -NAME (First, Middle, Last, Suffix) John Merlin Curl 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Esther Nachtigal 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 02/07/1963- 02/06/1967 14a. INFORMANT -NAME Carla Vingom 14b. RELATIONSHIP TO DECEDENT Daughter 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.) February 3, 2015 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) 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 I 18. PART I. Enter the chain of events - diseases, injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death Less Than 6 Hours 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) sudden Cardiac Death, Severe Coronary Artery Disease, Three - vessel disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b) 1 any, leading to the cause listed I I on line a. DUE TO, OR AS A CONSEQUENCE OF: i onset to death Enter the UNDERLYING CAUSE c) I (disease or injury that initiated I I the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) 1 I 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART I. Dilated Cardiomyopathy, Chronic Atrial Fibrillation, Diabetes Mellitus, Acute Renal Failure, Hyperlipidemia, Depression 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death El 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 Investigat ❑ 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 & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE Z W r 1 u ; 23a. DATE OF DEATH (Mo., Day, Yr.) February 1, 2015 Z B g z T e n a c u W 2 G p 12 § 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) February 2, 2015 23c. TIME OF DEATH 10:34 AM 24e. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3d. To the best of my knowledge, death occurred at the time, date and place E C and due to the cause(s) stated. (Signature and Title) f Jane A. McDonald, 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 cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE I j o (� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) February 6, 2015 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH„..ANOOMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA D4R TIvitNt OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FQR'VITAL RECORDS. DATE OF ISSUANCE 02/10/2015 LINCOLN, NEBRASKA CERTIFICATE OF DEATH 201501586 STAIVLEY S OORER ASSISTANT 9TA■TE�REGISTRAR, DEPARTh EAIT OF>J-lt.ALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES'