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<br /> STATE �F NEBRASKA
<br /> WI-��N THIS��PY�AR14�E5 THF RA�SED SEAL DF THE II�EI3��.4SICA DEPA R T�►�1FNT DF NFAL TH AND HUMAlV SFI4 V.�CES,�T CER TIF�ES
<br /> THE BEL�W T�BE R TI4�IE CDPY OF THE�I4I�INAL 14ECDRD a1V F.�LE W�TH THE NEBRASfCR DEPAR TMEIIlT�F NEALTH AIVD
<br /> HUNIRN SEI4V�CE5� V�TAL REC�14l75 DFFICE, WH�CH�S THE LEGAL❑EPC75�T�RY F�R V�TAL 14ECn14DS.
<br /> �A TF QF�SS UA IVC� �
<br /> �71��1��15 STANLEY S. CD�PEJ4
<br /> ASSISTAlI1T STATF REGISTRAR
<br /> DEPARTMFNT QF H�ALTH Alll�
<br /> L�lVCOLN, II�E614ASKA HC1NlAIV SE'RVI�ES
<br /> STATE�F NEBRASKA-❑EPARTMENT QF HEALTH AND HIJNfAN SERV[CES ,���,��g�
<br /> CERTIFI�ATE�F DEATH
<br /> �.DECEflENT'S-NAME �First, Middle, tast, 5uff�x) �.SE]{ 3.DATE DF❑�ATH tMo,,Day,Yr.y
<br /> Earl La►►ern Shehein Mafe March 2,2015
<br /> 4.CITY AiVD STATE❑R TERRIT(]RY,�R F�REfGN CDl1NTRY�F BIRTH 5a.AGE-Last Bi�thday F�,LJNE]ER 1 YEAR 5�.11N0ER'!DAY �.DATE Q�B1RTH�Mv.,Day,Yr.)
<br /> (Y�•f M05. ❑AYS H�LJR5 MINS.
<br /> Doniphan,Nehraska 82 April�, �932
<br /> 7.S��IAI�SECURITY NUMBER Sa.PLAC��F DEATH
<br /> �j0�j_3$-7�$J H05PITA� �Ir�patient aTHER �Nursing Hame1LTC �Hospice Facility
<br /> 8b,FACIL.ITY-NAME�If not insti#utivn,gi�e street ar�d nurnbsr� []ER1Qutpatient []Decedent's Fiome
<br /> �
<br /> � CHI H��Ith St.Francis ❑vva ❑Other�Specify)
<br /> t�
<br /> � 8c,ClTY QR TQWN QF DEATH tlnclucie�ip Code] Sd.CQUNTY DF D�ATH
<br /> �
<br /> o Grand Island 68803 Hal�
<br /> °w�"� 9a.RESIDENCE-STATE 9b.CDUNTY 9c.CfTY DR TaWN
<br /> Nebraska Hall Grand island
<br /> � 9d.STREET AN❑NUMBER 9e.APT.ND. 9f.ZIP CQ[]E 9g.IN51t]E CITY LIMiTS
<br /> T 5Z5 Kennedy❑rive �$$�3 [� YE5 ❑ Na
<br /> � 10a,MARITA4.STAT�S AT T1ME QF❑EATH�11Aarri�d �}Never MarrEed 1Db.NAME�F SPDLISE�F9rst, Middle, Last, Suffix)If wife,gi�e maiden name
<br /> �
<br /> a�
<br /> �= ❑Married,but separat�d ❑Widvwed ❑❑ivvrc�� ❑Unknawn ❑onna Garpenter
<br /> �
<br /> �
<br /> � 97.FATHER`S-NAME �First, Middie, Last, 5uffix� 92.MQTHER'S-NAME �First, Middle, Maiden Surnam�)
<br /> � Uavid Earl 5hehein Bur� Mary Jacksvn
<br /> m
<br /> °' 13.EVER IN U.5.ARMED��RGE5? Give dates of s�rviGe if Yes. 14a.INFQRMANT-NAME 14b.RELAT�ONSHIP TO DEGEDENT
<br /> E
<br /> � tv�s,No,or LJnk.y YB5 ���1811952-�11Q21�954 ❑onna 5hehein Spouse
<br /> � i5.METHaD Q�DISPQSITIDN 1Sa.EMBALMER-SIGNATURE 16b.t10EN5E N�. 1Gc.DATE�Mv.,Day,Yr.]
<br /> �
<br /> � �Burial ❑Donation
<br /> Chris McCoy �19'I Mar�h�,2�15
<br /> ❑Cremativn ❑Entombment �6d.CEMETERY,CREMAT4RY QR QTH�R LQCATION C1TY1 T�WN STATE
<br /> ❑�temoval ❑�ther�5pecify]
<br /> �edarv�ew Cemetery Doniphan N�braska
<br /> 17a.�k1NERAL HQME NAME AN!]MAII.ING ADDRESS�5treet,Clty ar Tvwn,Statey 17b•��p����
<br /> Apfel Funeral Home, �123 VI1.�nd,Grand Island,Me�raska �8801
<br /> CAUSE OF DEATH See instructions and�xam 1es
<br /> 18.QART I.Enter the chain af ever+ts--diseases,inj�ries,or eomplieations-tftat directly caused tne death,�n NOT enter terminal events su�h as cardiac arrest, � APPROXIMATE INTERVAL
<br /> respiratory arrest,or�entr':cular f brillativn without shawing the etialogy.DD NOT A�3BR�VIAT�.EntBr anly one cause an a line.Add additional lines if necessary. �
<br /> EMMEDIATE CAUSE: i anset ta d�ath
<br /> IMMEAIA"TE CAUS�(Finai a�Cardiapulmonaey Arres� � Immediat�
<br /> disease or cpnditian resulting �
<br /> �
<br /> In death] p�E T�,OR A5 A�QNSEQUENCE OF:
<br /> � onset to death
<br /> Sequentiaiiy list conditians,if by Myocardial lnfarction � ��❑�]��
<br /> any,leading to th�cause listed �
<br /> 1
<br /> on line a,
<br /> Dll�TQ,DR A5 A CaNSEQIJENCE DF: i anset to deat�
<br /> Enter the UNi7Eftl.YINf3 CAl1SE �� �
<br /> I
<br /> (disease or injury that initiated
<br /> the e�ents resuiting in deathy ❑UE T�,OR AS A CQNS�L�UENCE C�F: � anset tv death
<br /> LAST d� `
<br /> I
<br /> 18.PART�I.�THER 51GNIFICANT CONOiTI�NS-Conditivns contributing to the death hut nat rssulting in the underfying cause given in PART I. 19.WAS MED�CAL EXAMENER
<br /> �bstructive L.ung❑isease,myasthenia Gravis, DR CQR�N�R C�NTACTED?
<br /> � ❑YES �N�
<br /> W �Q.1F FEMALE: 21a.MANMER aF❑EATH 2ib,IF TRANSPaRTATI�N iNJIJR 21e.WAS AN AUTOPSY PE�tFQRMED?
<br /> �
<br /> � �Nnt prcgnant within past year �Natural �Hamicsde �Dri�erlL]perstor
<br /> ❑ v�s p n�o
<br /> W Pregnant at time af death � ❑ �Aassenger
<br /> � ❑ Accident Pending lnvestigatiar�
<br /> �Npt pregnant,�ut pregnant within 4�qays of death �Pedestrian 21 d.WERE AUTQPSY FINDIN�S AVAILAB�
<br /> � �5uicide �Cauld nat be det�rmined TQ COMP�ETE CAI�SE OF DEATH7
<br /> � �Not pregnant,but pregnant 43 days to 1 year befare death �Dther t5pecify)
<br /> � �tlnknown if pregnant within the past year ❑ YES [] N❑
<br /> �' 22a.DATE flF INJURY{Ma.,Day,Yr.y �2�.TIME�F!NJ!!RY 22c.P1.ACE D�INJURY-At hvme,farm,street,factary,offi�e huilding,constructivn sit�,etG,tSpecify�
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<br /> 0
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<br /> ,�i�, �2d.INJIJRY AT W�RK? 2�e.❑E5CRI9E H[7W INJl1RY aCGIJRRED
<br /> 0
<br /> �' �Y�5 �MQ
<br /> 22f.L.QCATIQN OF INJIJRY-STREET g IVUMBER,APT.N�, CITYlTOWN STATE ZIP CQDE
<br /> �3a.DATE��DEATH�Mo.,Day,Yr.) � � �4a.[]ATE SIGNED tMo.,Da�y,Yr.y 24b.TIME I]F DEATH
<br /> �� March 2,2015 �a�
<br /> U �
<br /> � � r �3b.❑ATE SIGNED�Mo.,❑ay,Yr.� Z3c.TIME�F DEATH �� �� 24c.PRDAIt]UNCEE3 DEA��Mv.,Day,Yr. Z4c#.TIME PRQN�LJNCED�EAD
<br /> �� ,z fVlarch 3,2D�15 D3:34 PM �a �z
<br /> �
<br /> � � � 2 3 d.Tv t he best o f my know i�a lge,dea t h occurre d at t he time,date and plaae �W �� xe}e,On the basis of examination andlar investigatian,in my apinian deat F t a�curre c f a t
<br /> � and due to the cause�s]s#ated.(5ignature and Title) �� ❑ #he time,s#ate and place ant�rlue ta the eause(s)stated.t5ignature and Title`
<br /> v � o� V
<br /> ~❑ O
<br /> ~ � Ryan❑.Crouch,D� �
<br /> 25.�I❑T�BACCO L1SE GnNTRlB�TE TD THE DEATH? �Ga,HA5 ORGAN QR TES5UE DDNATl�N BEEN C�N510ERED? 26b.WAS CONSENT GRANTED?
<br /> [�YE5 []N� ❑PRDBABLY [] �N�[N�WN �YE5 �]N❑ Not Applicable if�6a is NQ []YE5 []N�
<br /> Z7.NAME,TITLE AN❑AD� ype or Print
<br /> Ryan D.Crvuch,DC],8��N Alpha Street,Grand Island,Nebraska,�8803
<br /> 28a.REGISTRAR'S 51GNATlJRE � 28p.DATE FILED BY REGiSTRAR�Mo.,[]ay,Yr.y
<br /> ~ March 5,�0�5
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