To be completed/verified by: FUNERAL DIRECTOR I
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Robert Bruce McClurkin
<br />2. SEX ) p
<br />Male
<br />13.Fa TE OF'DEATI4 (Mo., Day, Yr.)
<br />, . Juge.11, 2014
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Rural Shelton, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />93
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />May 4, 1921
<br />MO3.
<br />I
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />507 -14 -2235
<br />Bb. FACILITY -NAME (if not Institution, give street and number)
<br />Grand Island Veterans Home
<br />_
<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 />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />I Hall
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />STREET AND NUMBER
<br />4252 Lariat Lane
<br />e. APT. NO.
<br />re.
<br />I
<br />91. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />I 0 YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) H wife, give maiden name
<br />Ruth Elaine McDaniel
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Samuel George McClurkin
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Vera Frances Likes
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) Yes 12/16/1943 - 12/12/1946
<br />14a. INFORMANT -NAME
<br />Ruth Elaine McClurkin
<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 />June 13, 2014
<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 />To be completed by: CERTIFIER
<br />15. PART I. Enter the chain of events- -diseases, Injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac avast, APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. 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) MRSA Sepsis Days
<br />disease or condition resulting
<br />in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Sequentially list conditions, if b)
<br />any, leading to the cause listed
<br />line
<br />on a. DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE C)
<br />(disease or injury that initiated
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the de but not resulting in the underlying cause given In PART I.
<br />Anemia; Chronic Kidney Disease; Coronary Artery Disease.
<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 ❑ Couid not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />❑YES El NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />construction site, etc. (Specify)
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home,
<br />farm, street, factory, office building,
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />.2 1
<br />E I t� >-
<br />u 21
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 11, 2014
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />June 12, 2014
<br />23c. TIME OF DEATH
<br />I 06:30 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />Jd. To the best of my knowledge, death occurred at the time, date and place
<br />2 and due to the cause(s) stated. (Signature and Title)
<br />2 Gene L. Wyse, DO
<br />24e. 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
<br />0 YES 0 N 0 PROBABLY 0 UNKNOWN ❑ YES
<br />ISSUE DONATION BEEN CONSIDERED?
<br />)3 •
<br />26b. WAS CONSENT GRANTED?
<br />f Not Applicable if 26a Is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Gene L. Wyse, DO, 2300 West Capital Avenue, Grand Island, Nebraska, .803
<br />128a REGISTRAR'S SIGNATURE /�
<br />(�
<br />28b. DATE FILED BY REGISTRAR (MO., Day, Yr.)
<br />June 16, 2014
<br />201507822
<br />DATE OF ISSUANCE
<br />06/17/2014
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OP ANN/4,1041y SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKK''t EPA, M' QF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FO - tb� � f )$
<br />•
<br />STAI eY S. COr3PER '.'„
<br />DEP.4RTMEN.T h1HA AND
<br />Ht%M MSERVICES , s .
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERLpCt& ^r! 3 "/ b
<br />' '' -14 02943
<br />CERTIFICATE OF DEATH
<br />
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