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To be completed by: CERTIFIER I I To be completed/verified by: FUNERAL DIRECTOR I <br />1. DECEDENTS -NAME (First, Middle, Last, Suffix) <br />Laverne Gaylord Throop <br />2. SEX <br />Male <br />3. DATE OF DEATH (Mo., Day, Yr.) <br />September 17, 2015 <br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH <br />Boelus, Nebraska <br />5a. AGE - Last Birthday <br />(Yrs.) <br />86 <br />5b. UNDER 1 YEAR <br />5c. UNDER 1 DAY <br />6. DATE OF BIRTH (Mo., Day, Yr.) <br />October 26, 1928 <br />MOS. <br />DAYS <br />HOURS <br />MINS. <br />7. SOCIAL SECURITY NUMBER <br />508 -30 -4755 <br />8a. PLACE OF DEATH <br />HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility <br />❑ ER/Outpatient ❑ Decedent's Home <br />❑ DOA ❑ Other (Specify) <br />8b. FACILITY -NAME (If not Institution, give street and number) <br />Tiffany Square Care Center <br />Sc. 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 />Sc. CITY OR TOWN <br />Grand Island <br />9d. STREET AND NUMBER <br />1417 Sheridan Place <br />e. APT. NO. <br />r <br />9f. ZIP CODE <br />I 68803 <br />9g. INSIDE CITY LIMITS <br />® YES ❑ NO <br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married <br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown <br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name <br />Dorothy Florence Jensen <br />11. FATHER'S -NAME (First, Middle, Last, Suffix) <br />Ben Throop <br />12. MOTHER'S -NAME (First, Middle, Maiden Surname) <br />Gladys Lemburg <br />13. EVER IN U.S. ARMED FORCES? Glve dates of service if Yes. <br />(Yes, No, or Unk.) Yes Dates Unknown <br />14a. INFORMANT -NAME <br />Dorothy Florence Throop <br />14b. RELATIONSHIP TO DECEDENT <br />Wife <br />15. METHOD OF DISPOSITION <br />❑ Burial ❑ Donation <br />® Cremation 0 Entombment <br />❑ Removal ❑ Other (Specify) <br />16a. EMBALMER - SIGNATURE <br />Not Embalmed <br />16b. LICENSE NO. <br />16c. DATE (Mo., Day, Yr.) <br />September 19, 2015 <br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE <br />Central Nebraska Cremation Services Gibbon Nebraska <br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) <br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska <br />17b. Zip Code <br />68801 <br />CAUSE OF DEATH (See instructions and examples) <br />16. 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, r APPROXIMATE INTERVAL <br />respiratory arrest, or ventricular fibrillation without showing the ecology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. <br />IMMEDIATE CAUSE: onset to death <br />IMMEDIATE CAUSE (Final a) Respiratory Failure < 1 Week <br />disease or condition resulting <br />in death) DUE TO, OR AS A CONSEQUENCE OF: j onset to death <br />Sequentially list conditions, if b) Metastatic Renal Cell Carcinoma 1 > 1 Month <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) I <br />(disease or Injury that initiated <br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death <br />LAST d) 1 <br />I <br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given In PART I. <br />19. WAS MEDICAL EXAMINER <br />OR CORONER CONTACTED? <br />❑ YES ® NO <br />20. IF FEMALE: <br />❑ Not pregnant within past year <br />❑ Pregnant at time of death <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 />21a. MANNER OF DEATH <br />® Natural ❑ Homicide <br />❑ Accident ❑ Pending 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 />21d. WERE AUTOPSY FINDINGS AVAILABLE <br />TO COMPLETE CAUSE OF DEATH? <br />❑ YES ❑ NO <br />22a. DATE OF INJURY (Mo., Day, Yr.) <br />22b. TIME OF INJURY <br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) <br />22d. INJURY AT WORK? <br />DYES 0 N <br />22e. DESCRIBE HOW INJURY OCCURRED <br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE <br />2 W <br />1 G <br />E u i <br />23a. DATE OF DEATH (Mo., Day, Yr.) <br />September 17, 2015 <br />.2 g _ <br />o k Y <br />g a. a o <br />W z <br />o a z <br />~ g s <br />24a. DATE SIGNED (Mo., Day, Yr.) <br />24b. TIME OF DEATH <br />23b. DATE SIGNED (Mo., Day, Yr.) <br />September 17, 2015 <br />23c. TIME OF DEATH <br />10:10 AM <br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) <br />24d. TIME PRONOUNCED DEAD <br />0 3d. To the best of my knowledge, death occurred at the time, date and place <br />Z o C end due to the cause(s) stated. (Signature and Title) <br />E Jennifer L. Brown, MD <br />24a. On the basis of examination and/or investigation, in my opinion death occurred at <br />the time, date and place and due to the cause(s) stated. (Signature and Title) <br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO <br />26b. WAS CONSENT GRANTED? <br />Not Applicable if 26a Is NO ❑ YES ❑ NO <br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print <br />Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 <br />28a. REGISTRAR'S SIGNATURE A . <br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) <br />September 22, 2015 <br />STATE OF NEBRASKA <br />2015076'33 <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH A Q 4/MAN SERVICES, IT CERTIFIES <br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA p PA TIWT OF HEALTH AND <br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL 'yR X O,*I'IS <br />DATE OF ISSUANCE <br />STANLEY S. COOPER <br />ASSISTANT STATE REGISTRAR <br />DEPARTMENT OF HEALTH AND <br />LINCOLN, NEBRASKA HUMAN SERVICES <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SLRYIDEB' <br />10/01/2015 <br />CERTIFICATE OF DEATH <br />