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To be completed by: CERTIFIER 1 1 To be completed /verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) 2 2. SEX -' ;, .' -' : '.a.OATE:$F D DEATH (Mo., Day, Yr.) 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5 5a. AGE - Last Birthday 5 5b. UNDER 1 YEAR 5 5c. UNDER ?.D _ 6 6. DATE OF BIRTH (Mo., Day, Yr.) (Yrs.) M MOS. D DAYS H HOURS M MINS. February 14, 1933 7. SOCIAL SECURITY NUMBER 8 8a. PLACE OF DEATH ❑ ER/Outpatient ❑ Decedent's Home 8b. FACILITY -NAME (If not Institution, give street and number) ❑ I8d, COUNTY OF DEATH 9a. RESIDENCE -STATE 9 9b. COUNTY 9 9c. CITY OR TOWN 9d. STREET AND NUMBER 9 I 9f. ZIP CODE 9 9g. INSIDE CITY LIMITS 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married l lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name 11. FATHER'S -NAME (First, Middle, Last, Suffix) 1 12. MOTHER'S -NAME (First, Middle, Maiden Surname) 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. 1 14a. INFORMANT -NAME 1 14b. RELATIONSHIP TO DECEDENT 15. METHOD OF DISPOSITION 1 16a. EMBALMER- SIGNATURE 1 16b. LICENSE NO. 1 16c. DATE (Mo., Day, Yr.) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) 1 17b. Zip Code CAUS OF DEATHjSee instructions and examples) 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 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: onset to death IMMEDIATE CAUSE (Final a) Metastatic Adenocarcinoma Pathology of Cells Suggests Lung Prior disease or condition resulting n death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST 1 d) 1 1 18. PART 1I. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 1 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE: 2 21a. MANNER OF DEATH 2 21b. IF TRANSPORTATION INJURY 2 21c. WAS AN AUTOPSY PERFORMED? 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? 22a. DATE OF INJURY (Mo., Day, Yr.) 2 22b. TIME OF INJURY 2 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? 2 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE W a 23a. DATE OF DEATH (Mo., Day, Yr.) z z y 2 24a. DATE SIGNED (Mo., Day, Yr.) 2 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) 1 2 23c. TIME OF DEATH T 8 < 0 3d. To the best of my knowledge, death occurred at the time, date and place u 24e. On the basis of examination and /or investigation, in my opinion death occurred at 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR I ISSUE r • ATION BEEN CONSIDERED? 2 26b. WAS CONSENT GRANTED? 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Michael A. Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 r 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, : VI:ML RECORDS. ' DATE OF ISSUANCE 201506637 - STANLEYS COOPEk ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND LINCOLN, NEBRASKA HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 06/25/2015