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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 />