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STATE OF IOWA
<br />CERTIFICATION OF VITAL RECORD
<br />BIRTH
<br />NUMBER
<br />1. DECEDENT'S
<br />FULL NAME
<br />12a. RESIDENCE -STATE
<br />Nebraska
<br />FIRST
<br />Donald
<br />2, SEX 3. AGE - LAST BIRTHDAY
<br />Male 82
<br />6. PLACE OF BIRTH (City & State or Foreign Country)
<br />Litchfield, Nebraska
<br />9. MARITAL STATUS AT TIME OF DEATH
<br />$(Monied ❑ Married, but separated ['Widowed
<br />0 Divorced 0 Never Married ❑ Unknown
<br />12b. RESIDE C
<br />13.FATHERS FIFIST MIDDLE
<br />.. arnVo rT.ar11S
<br />15a. INFORMANTS
<br />NAME LaVon LaRae Mason
<br />IF DEATH OCCURRED IN A HOSPITAL
<br />0 Inpatient D ER/Outpatient D Deed on Arrival
<br />17a. FACILITY NAME (If not institution, give street and number)
<br />Tabor Manor Care Center
<br />18. METHOD OF DISPOSITION
<br />®.Burial D Cremation D Donation ['Entombment ❑ Removal from State
<br />❑ Other (Specify)
<br />20. LOCATION OF DISPOSITION (City or Town & State)
<br />22a. FUNERAL DIRECTOR - Printed Name
<br />Craig A. Marshall
<br />ITEMS 24 -28 REQUIRED TO BE COMPLETED BY
<br />PERSON WHO PRONOUNCES OR CERTIFIES DEATH
<br />6 N O F PERS PERSON DEATH (If different than certifier) (Type or print legibly)
<br />Jennifer Skokan
<br />LAST
<br />iviaaort
<br />29. ACTUAL OR PRESUMED DATE OF DEATH
<br />(Month, Day, Year) (Spell out Month) January 27, 2014
<br />IMMEDIATE CAUSE (Final disease or
<br />condition resulting in death) - ...... +
<br />Sequentially list conditions, if any. leading to
<br />the cause fisted on line a. Enter the
<br />UNDERLYING CAUSE (disease or injury that
<br />initiated the events resulting in death)LAST
<br />35. DID ".C'BA000 USE
<br />CONTRIBUTE TO DEATH
<br />44. DESCRIBE HOW INJURY OCCURRED'.
<br />STATE OF IOWA
<br />IOWA DEPARTMENT OF PUBLIC HEALTH
<br />CERTIFICATE OF DEATH
<br />MIDDLE LAST
<br />Dean Mason
<br />Hours I Minutes
<br />7. CITIZEN OF WHAT COUNTRY?
<br />United States
<br />10 DECEDENTS LAST NAME. PRIOR TO ANY
<br />MARRIAGE (If ever married)
<br />Mason
<br />12c.RESID N E- ITY OR
<br />Grand Island
<br />14. MOTHER'S FIRST
<br />I I O ANY r.AARRiAGE
<br />156, INFORMANT'S MAILING ADDRESS (Street & Number, City, State, Zip Code)
<br />4240 Utah Ave., Grand Island, NE 68803
<br />16. PLACE OF DEATH (Check only one)
<br />IF DEATH OCCURRED SOMEWHERE 0 (HER THAN A HOSPD AL
<br />❑ Hospice Facility MI Nursing Horne /Long -Term Care Facility D Decedent's Home O Other (Speciry)
<br />17b. CITY, TOWN, OR LOCATION 5 ZIP CODE OF DEATH
<br />Tabor 51653
<br />DISPOSITION
<br />19. PLACE OF DISPOSITION (Name of Cemetery , Crematory. or other place)
<br />21. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY
<br />Crawford- Marshall Funeral Chapel 602 Orange /Box 253 Tabor , IA 51653 -0253
<br />PRONOUNCEMENT, CE T (CATION, AND CAUSE OF DEATH
<br />24. DATE PRONOUNCED DEAD onth. Day, Year) (Spell oUt month)
<br />January 27, 2014
<br />39. TIME OF INJURY 0 AM 0 PM
<br />22b. FU - ua_ TOR -Si. ' r
<br />TIME 0 Military
<br />27. TITLE
<br />LPN
<br />CAUSE OF DEATH (see instructions and examples)
<br />32a. PART 1. Enter the chain of events - diseases, injuries, or complications that directly caused the death. 20 NOT enter terminal events such as cardiac arrest-- -
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional line if necessary.
<br />(A./tAe4`e, C ? -4' S
<br />Due to (or as a consequence of),
<br />Due to (or as a consequence et)
<br />DOS l0 (Or as a consequence of)
<br />Uue to or as a consequence of).
<br />32c. PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART 1
<br />42. LOCATION OF INJURY (Complete physical address_ Street & Number, Apt. 5, City or Town, State. Zip Code)
<br />4.DATE OF BIRTH (Month, Day, Year)
<br />October 31, 1931
<br />11, SURVIVING SPOUSE (Full name prior to any marriage)
<br />LaVon LaRae Heisner
<br />12d. RESIDENCE -STREE
<br />36. iF FEMALE'.
<br />D No; pregnant under past year 0 Not pregnant, but pregnant within 42 days of death
<br />Yes D Probably D Pregnant at time of death D Not pregnant, but pregnant 43 days to 1 year before death
<br />No D Unknown D Unknown if pregnant within the past year
<br />38. BATE OF INJURY (Month, Day, Year) (Spell out month)
<br />& NUMBER, ZIP
<br />4240 Utah Ave. 68803
<br />MIDDLE
<br />28. LICENSE NUMBER
<br />P57483
<br />30. ACTUAL 013 PRESUMED CS TIME or DEATH
<br />TIME 8 :05 D AM 1 PM 0 Military
<br />40. PLACE OF INJURY (e.g., home, farm, street, roadway, etc)
<br />FORM #588 0328C(03/2010) WARNING: IT IS ILLEGAL TO DUPLICATE THIS COPY
<br />5. COUNTY OF DEATH
<br />8. EVER IN U.S. ARMED FORCES
<br />16 Yes D No
<br />Fremont
<br />201506869
<br />12e.113 IDE
<br />CITY LIMITS?
<br />® Yes ❑ No
<br />I .S(
<br />Fowiie
<br />16c. RELATIONSHIP TO DECEDENT
<br />Wife
<br />170. INSIDE CITY LIMITS?
<br />ED Yen ❑ No
<br />23, LICENSE NUMBER
<br />2327
<br />SUFFIX, it any
<br />25. TIME PRONOUNCED DEAD
<br />TIME 8:05 DAM N.PM ❑Military
<br />11. MEDICAL EXAMINER
<br />CONTACTED? ❑ Yes to No
<br />31b. (f Yes, M. E, cpe number
<br />326. Approximate
<br />interval between onset
<br />and death
<br />33.WAS AN AUTOPSY PERFORMED? ❑ Yes 16 No
<br />34. WERE AUTOPSY FINDINGS .AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH, D Yes D No
<br />37. MANNER OF DEATH
<br />, .Stunt 0 Homicide
<br />D Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be Determined
<br />41. INJURY AT WORK?
<br />D Yes ❑ No
<br />43. IF TRANSPORTATION INJURY, SPECIFY.
<br />❑ Driver /Operator 0 Passenger 0 Pedestrian
<br />D Other (Specify)
<br />45. CERTIFIER [Certifying MD, D0, PA, ARNP • To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated.
<br />CC (Check only one) D Medical Examiner - On the basis of examination and/or investigation. h my opinion, death occurred at the lime, date, and place, and due to the cause(s) and manner stated. }
<br />ky Signature -- 46. TITLE 47. DATE CERTIFIED (Month, Day, Year) 0 I- / " /
<br />I- 48. NAME 8 COMPLETE MAILING ADDRESS OF CERTIFYING PHYSICIAN OR MEDICAL EXAMINER 49. L 2 ICENSE NUMBER
<br />E Dr. Michael Schmiesing, I. 320 Ebaugh - Glenwood, IA 51534
<br />0 SOa. COUNTY OF REG:4TRATION(County of Deatn) STRAIT SIGN
<br />Fremont
<br />50c. DATE FILED (Monti jay, Year)
<br />January 31, 2014
<br />This is to certify that this is a true and correct reproduction of the original record as recorded
<br />in this office, issued under authority of Chapter 144, Code of Iowa.
<br />This copy not valid unless . red on engraved border displaying state seal and signature of the Registrar.
<br />AN Al /ri B o Fremtn.+
<br />DATE ISSUED COUNTY REGISTRAR OF VITAL RECORDS COUNTY
<br />120.1.1.V
<br />Co
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<br />5 ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE '1,1 -.
<br />4
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