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To be completed /verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Merlin Clair Fuller 2. SEX Maleuiy 3. 6A E dff°bEATH (Me., Day, Yr.) 7, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH St. Paul, Nebraska 5a, AGE - Last Birthday (Yrs.) 81 5b. UNDER 1 YEAR 5c. UNDER" I ' 6. DATE OF BIRTH (Mo., Day, Yr.) October 9, 1932 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -28 -1187 8b. FACILITY -NAME (If not Institution, give street and number) Park Place -A Golden Living Center 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other(Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 66803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE - STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 4093 Zola Lane 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS IA YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Jean Maurine Larson 11. FATHER'S -NAME (First, Middle, Last, Suffix) Clifton Eugene Fuller 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Lillian Robinson 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or link.) No 14a. INFORMANT -NAME Jean Maurine Fuller 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Tracey Dietz 16b. LICENSE NO. 1328 16c. DATE (Mo., Day, Yr.) July 11, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 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: IMMEDIATE CAUSE (Final a) Chronic Obstructive Lung Disease disease or condition resulting onset to death 3 Years In death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b) I any, leading to the cause listed I I on line a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) I (disease or injury that initiated ; the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) I I I 18. PART H. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Amyloidosis 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20.1F FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown it pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide Accident Pending Investigation ❑ ❑ ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? DYES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE a w 8 E u z 23a. DATE OF DEATH (Mo., Day, Yr.) July7,2014 Z avE i i Y ° a t, m w ¢ O 2 o c U U ` s 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) July 8, 2014 23c. TIME OF DEATH 12:58 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 a 0 3d. To the best of my knowledge, death occurred at the time, date and place g c and due to the cause(s) stated. (Signature and Title) David R. Golan, MD 2de. On the basis o1 examination antllor investigation, in my opinion death occurred at the time, date and Glace and due t0 the causes) sta ted. (Sidnature and Titix) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print David R. Colan, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE A - � V 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I July 10, 2014 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 DEP444,T.QIT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITA S CORp DATE OF ISSUANCE STATE OF NEBRASKA 201,08019 STANLEY .6•OOPER ASSLJAAT STATE REGISTRAR DE64RTMEN 1.1EALTil AND LINCOLN, NEBRASKA HUMAN SER t , , ,, STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 07/14/2014