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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANQ,IUt� `/`IAA 'SEf{VICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA •pEP4k7M' ENit QE ALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITALRRCQ •t •, d ,
<br />•
<br />CERTIFICATE OF DEATH E.
<br />DATE OF ISSUANCE 201502513 /.d�,A�lrurJt
<br />ASSISTANT Tkt CRECirLSTRAR
<br />DEPARrAffer OF ) ; 'I ;ANQ
<br />LINCOLN, NEBRASKA ,HUMA I ' SER CES. , , .a.
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES ( 4' ` )'
<br />11 01558
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Paul Gene Crow
<br />2. SEX "
<br />Male
<br />3, DATE OF DEATH (Mo., Day, Yr.)
<br />'April 21, 2011';.,
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />75
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />August 10, 1935
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />507 -32 -9120
<br />8a. PLACE OF DEATH
<br />}IOSPITAL ❑ Inpatient OTHER ®Nursing Home/LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME (H not Institution, give street and number)
<br />Park Place-A Golden Living Center
<br />❑ ER/Outpatlent ❑ Decedent's Home
<br />❑ DOA ❑ Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />19e. CITY OR TOWN
<br />Grand Island
<br />STREET AND NUMBER
<br />1203 East 6th Street
<br />re.
<br />I e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />O YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Carol Castor
<br />it FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Richard W Crow
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Edna Robertson
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes.
<br />(Yes, No, or Unk.) Yes 07/17/1958 - 12/19/1958
<br />14a. INFORMANT -NAME
<br />Carol Crow
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />18a. EMBALMER-SIGNATURE
<br />Tracey Dietz
<br />16b. LICENSE NO.
<br />1328
<br />18c. DATE (Mo., Day, Yr.)
<br />April 25, 2011
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART I. Enter the chain of events -- diseases, injuries, or compliationsthat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Days
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Subdural Hematoma
<br />disease or condition meeting
<br />in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Sequentially list conditions, if b) Head Trauma
<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 d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resuftIng In the underlying cause given In PART I.
<br />Atrial Fibrillation, Weakness
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES 0 N
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />P
<br />❑ Pregnant an at time of death
<br />21a. MANNER OF DEATH
<br />❑ Natural ❑ Homicide
<br />®Aceldant 0 Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ® NO
<br />❑ Not pregnant, 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 past year
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />Unknown
<br />22b. TIME OF INJURY
<br />Unknown
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />Home
<br />22d. INJURY AT WORK?
<br />❑ YES ® No
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />Patient had history of many falls. Many were unwitnessed. This injury was unknown.
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />Unknown, Unknown Unknown
<br />E' W
<br />t r
<br />I to
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 21, 2011
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<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />May 11,2011
<br />23c. TIME OF DEATH
<br />I 07:57 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />8 5 D 9d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the ause(s) stated. (Signature and Title)
<br />a Travis S. Hageman, MD
<br />tae• the On the time, mesh of date and place nd aand examination due t and/or t 0 the he ueale cause(a) stated. my opinion ated. (Signana ture and an d Title) 0 at
<br />the
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN
<br />127. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN,
<br />Travis S. Hageman, MD, 729 North Custer Avenue,
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ® NO
<br />HYSECIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY A
<br />Grand Island, Nebraska, 68803
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑ YES ❑ NO
<br />ORNEY) (Type or Print)
<br />128a. REGISTRAR'S SIGNATURE
<br />46
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 11, 2011
<br />STATE OF NEBRASKA
<br />•
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANQ,IUt� `/`IAA 'SEf{VICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA •pEP4k7M' ENit QE ALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITALRRCQ •t •, d ,
<br />•
<br />CERTIFICATE OF DEATH E.
<br />DATE OF ISSUANCE 201502513 /.d�,A�lrurJt
<br />ASSISTANT Tkt CRECirLSTRAR
<br />DEPARrAffer OF ) ; 'I ;ANQ
<br />LINCOLN, NEBRASKA ,HUMA I ' SER CES. , , .a.
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES ( 4' ` )'
<br />11 01558
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