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1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Wayne Frederick Huebner i sei.5, h ' , ','. 1 I" ( A ` ' r raid. , , , , ,, `, 8t15A'T t$ DEATH (Mo., Day, Yr.) fA ' i'c';?.7, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 85 5b. UNDER 1 YEAR 5c. tlitIEF 4 DAN ' 6. ik4TE OF BIRTH (Mo., Day, Yr.) May 29, 1929 MOS. DAYS HOURS M 9 7. SOCIAL SECURITY NUMBER 506 -28 -7130 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/outpatient ❑`Deoedelft's'Home ❑ DOA ❑ Other(Specify) 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY I Hall 9c. CITY OR TOWN I Grand Island 9d. STREET AND NUMBER 511 W. 9th Street e. APT. NO. r 9f. ZIP CODE 68801 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 Emma Elizabeth Mueller 11. FATHER'S -NAME (First, Middle, Last, Suffix) Fred Huebner 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Minnie Luth 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No or Unk.) Yes Dates Unknown 14a. INFORMANT -NAME Emma Elizabeth Huebner 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) April 1, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Cemetery Grand Island 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) 12. PART I. Enter the g hain of events- diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Inc. l Add additional lines 1 necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final 8)Acute Cerebral Hemorrhage 1 Day disease or condition resulting In death) 1 onset to death DUE TO, OR AS A CONSEQUENCE OF: 1 Sequentially list conditions, if b) Hypertension 1 15 Years any, leading to the cause listed i on line a. DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death Enter the UNDERLYING CAUSE c) Coronary Artery Disease 1 15 Years (disease or injury that Initiated 1 the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death A d) 1 1 18. PART II. OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not resulting in the underlying cause given In PART I. Atrial Fibrillation, Asbestosis, Occipital Hematoma 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 it pregnant within the past year 21a. MANNER OF DEATH IE Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJUR ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. 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 B' W i r II 1 u z 23a. DATE OF DEATH (Mo., Day, Yr.) March 27, 2015 Z al $ i ' '�. T W 7 z o 2 C 8 g. g s 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) April 1, 2015 23c. TIME OF DEATH 06:45 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD g ex 0 3d. To the best of my knowledge, death occurred at the time, date and place o LT, and due to the cause(s) stated. (Signature nd Title) a William Landis, 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? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 265. 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 CERTI IT(Type or Print William Landis, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803 t28a. REGISTRAR'S SIGNATURE - 2DATE FILED BY REGISTRAR (Mo., Day, Yr.) I April 1, 2015 0 U cc 5 J z 7 a d c ar d a. 2 0 DATE OF ISSUANCE 05/22/2015 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITA REtbPGI .i. " 11�� [� { +s►� !� S7AA1L`EYCb�fIZ l�'r {� 151 tl / w .AS1$ISTANT STATE RESIST AR DEPAPT,M T FHEALTH'XIP�p LINCOLN, NEBRASKA ,'HUM V 1S RV jE$ : , STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN'ERVICES CERTIFICATE OF DEATH ` `' '•.'*l;