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To Be CompletedNerified by: FUNERAL DIRECTOR
<br />1
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />David Alan Bush
<br />2. SEX
<br />Male `
<br />.0ATE,_QF DkkTJI'(Mo.,Day,Yr.)
<br />February 9, 2014
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Paterson, New Jersey
<br />6e. AGE -Last Birthday
<br />(Yrs.)
<br />65
<br />6b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY'
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />"August 4, 1948
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />151-40 -9911
<br />8a. PLACE OF DEATH
<br />HOSPtTAL: ❑ Inpatient OTHER. ® Nursing Home/LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME (H not Institution, give street and number)
<br />Tiffany Square Care Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />❑ DOA ❑ OthegSpealty)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />2508 Stagecoach Rd
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />E Yes ❑ No
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />106. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Doris Jeanne Sheffield
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />William Bush
<br />12. MOTHER'S-NAME (First, Middle, Maiden Surname)
<br />Gertrude Zysling
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No _
<br />14a. INFORMANT -NAME
<br />Doris Jeanne Bush
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />❑ Berlal ❑DOnan °"
<br />®cremation ❑Entombment
<br />['Removal 0 Other(3peeily)
<br />18a. EMBALMER-SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />February 11, 2014
<br />ry
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />To Be Completed by: CERTIFIER
<br />CAUSE OF DEATH (See instructions and examples)
<br />1a. PART 1. Enter the cheIn °I nvente - diseases, Injuries,. or complications- that directly caused the death. Do NOT emer tennlnel events such as onliac arrest, APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation wtthout showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines B necessary.
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Final - , !
<br />disease in death
<br />or condition resulting a) � K � ,� "'f/ s , le 4�
<br />!!! �� „
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Sequentially list conditions, if b)
<br />any, leading to the cause listed
<br />on line a DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Condhions contributing to the death but not resulting In the underlying cause given In PART L
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES Igg40
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, b
<br />'but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑Unknown if pregnant within the pest year
<br />21a. MANNER OF DEATH
<br />[]1d�atural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />mi
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY �PERFORMED?
<br />�
<br />0 hl'NO
<br />21d. WERE AUTOPSY INDINGS AVAILABLE
<br />TO COMPLETE CAAUSE OF DEATH?
<br />0 YES [•/SO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YEs OTIO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET 8 NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />'`W
<br />a LL
<br />d a w Y
<br />W F
<br />J
<br />V <o
<br />o t7 /
<br />(
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 9. 2014
<br />1' c..)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />February 10. 2014
<br />23c. TIME OF DEATH
<br />8:36a m
<br />=
<br />I } O J
<br />E v, a Z
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />23d. the best of my knowledge, death occurred at the time, date and place
<br />a due to the cause(a) stated. (Signature and Tine)
<br />u g 0
<br />ft 0 O a t
<br />24e. On the basis of examination and /or investigation, in my opinion death occurred
<br />the tiros, date and piece and due to the cause(s) stated. (Signature and Title)
<br />25. DID C E CONTRIBUTjTO THE DEATH? 28a. HAS ORGAN OR TISSUE DO TION BEEN CONSIDERED?
<br />❑ Y LW ❑ PROBABLY ❑ UNKNOWN ❑ YES 6
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 281 is NO 0 YES NO
<br />1
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Dr. John Wagoner, 800 Alpha Street, Grand Island, NE 68803
<br />P
<br />28a. REGISTRAR'S SIGNATURE
<br />/ 44 ,(
<br />N` tq O
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />FEB 13 2014
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND H ? tfm SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE•NEBRASKA DEPARIVEN7 QF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FQR VITAL. RECORD.. " y ° •
<br />DATE OF ISSUANCE
<br />FEB 21 2014
<br />LINCOLN, NEBRASKA
<br />201502181
<br />t •
<br />A Ar r - j A ?' ••
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVlgt` . , ' �}
<br />CERTIFICATE OF DEATH 1 c- >. £r.
<br />,S,T4NLE , CPOfEg ,
<br />° ,A.SSIST T19 � EGISMAR,
<br />tD ;PARTMENT OF H ,4LTF,'4N, D,
<br />14101, SERVICES
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