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To be completedNerified by: FUNERAL DIRECTOR 1. DECEDENTS-NAME (First, Middle, Last, Suffix) James Daniel Washington 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) November 7, 2011 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Tahlequah, Oklahoma 5a. AGE - Last Birthday (Yrs.) 53 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) March 13, 1958 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 440 -68 -3126 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Home ❑ DOA ❑ Other(Specify) 8b. FACILITY -NAME (If not Institution, give street and number) 3012 N. Webb Road 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 3012 N. Webb Road 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® 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 Gerri Jo Zlomke 11. FATHER'S -NAME (First, Middle, Last, Suffix) Billy Gene Washington 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Sylvia Brown 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Gerri Washington 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) November 10, 2011 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Memorial Park Crematory Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livingston - Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 17b. Zip Code 68803 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 18. PART 1. 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 onset to death About 18 Months respiratory arrest, or ventricular fibrillation without showing the etiology. D0 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Metastatic Cancer Of Tongue Squamous Cell Carcinoma disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c ) (disease or Injury that Initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Hypertension, Hyperlipidemia 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 0 N 20. IF FEMALE: ❑ Not pregnant within past year ❑ P regnant 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 if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide 0 0 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? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE O, re 2 E >. E 1.1 z 23a. DATE OF DEATH (Mo., Day, Yr.) November 7, 2011 b' g i I = ,. E y a z 8 w i 0 8 z C ? S s 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) November 8, 2011 23c. TIME OF DEATH 05:20 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 0 3d. To the best of my knowledge, death occurred at the time, date and place 2 5 and due to the cause(s) stated. (Signature and Title) I) f Steven Husen, MD 248. On the basis of examination and/or investigation, In my opinion death occurred at the time, date and place and due 10 the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR I ❑ YES ISSUE DONATION BEEN CONSIDERED? El NO 28b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Islam. Nebraska, 68803 128a. REGISTRAR'S SIGNATURE x [`�'��{,• - �J 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I November 14, 2011 20Uv08571 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT oFttEALIV AkrtileiAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRskA`biAig 741fI r cif HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITA REG ,1/ S,, 6 t1 F.J STAI(.EY.S. ; PER *. I ,1 AS$ T'1Ty77 TTf RE 7RAR DEPARTMENT OF HEALT1-14ND LINCOLN, NEBRASKA 1 IUI$N SERVICES . ' STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 7 ,t; " " 11 03750 CERTIFICATE OF DEATH DATE OF ISSUANCE 11/15/2011 STATE OF NEBRASKA