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To Be CompletedNerified by: FUNERAL DIRECTOR I
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />James Edward Urban
<br />2. SEX
<br />Male
<br />-- '..f .,
<br />3. DATE OF DEATH (Mo.,Day,Yr.)
<br />November 8, 2015
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Loup City, Nebraska
<br />Sa. AGE-Last Birthday
<br />(Yrs.)
<br />55
<br />6b. UNDER 1 YEAR
<br />6c. UNDER 1 DAY
<br />S. DATE OF BIRTH (Mo., Day, Yr.)
<br />February 28, 1980
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />T, SOCIAL SECURITY NUMBER
<br />507 -90 -5823
<br />Sa. PLACE OF DEATH
<br />Menu ® Inpatient QTHER: ❑ Nursing Home1LTC ❑ Hospice Facility
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />❑ DOA ❑°ON'(sp.ah')
<br />6b. FACIU Y- NAME (N not institution, give street and number)
<br />CHI Health Immanuel
<br />Sc. CITY OR TOWN OF DEATH (include Zip Code)
<br />Omaha 68122
<br />ed. COUNTY OF DEATH
<br />Douglas
<br />Ba. RESIDENCE 4TATE
<br />Nebraska
<br />6b. COUNTY
<br />Hall
<br />tic. CITY OR TOWN
<br />Grand Island
<br />6d. STREET AND NUMBER
<br />1525 Stagecoach Road
<br />Se. APT. NO.
<br />W. ZIP CODE
<br />68801
<br />_
<br />9g. MODE CITY LIMITS
<br />® we ❑ No
<br />10e. MARITAL STATUS AT TIME OF DEATH ® Monied ❑ Never Marled
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />lab. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Celia Rose Wagner
<br />11. FATHER'S-NAME (First, Middle, Last, Suffix)
<br />Rudolph Urban
<br />12. MOTHER'S -NAME (First. Middle, Maiden Surname)
<br />Pauline Vahnout
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service N Yes.
<br />Wes, No, xrunk.) ` no
<br />14a. INFORMANT -NAME
<br />Celia Rose Urban
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16. METHOD OF DISPOSITION
<br />O&M! ❑D°""'en
<br />Ethemetion ❑ant
<br />❑Remerd ❑ oe%t weml
<br />16a. EMBALMER4IGNATURE
<br />Not Embalmed
<br />lab. LICENSE NO.
<br />16e. DATE (Mo., Day, Yr.)
<br />November 13, 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 />1Tb. Zip Code
<br />68801
<br />TO To Be Completed by: CERTIFIER
<br />CAUSE OF DEATH (See instructions and examples)
<br />111. PART!. Enter the %dole orewotr• diseases. Injuries, or eempllptlana•tlrt directly ceased the death. DO NOT entertennieel hones such es outlaw anew,
<br />meplralary urea, erwmdruW niMm Jan % showing the Mlehosy. DO NOT ABBREVIATE Enter only one mauve on a llea. Add additional line 6necepar.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final u C dlesase se or areondltonroealtlng s) V
<br />In death) 6
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />DUE TO, OAS A CONSEQUENCE
<br />Sequentially �� OF:
<br />any, to the cause conditions, a n.,�� i
<br />tm Y. Ieaatn9 me listed
<br />b) (bop � /1i ENC
<br />- ■
<br />j'(y{ f (�
<br />J am / ` UMJ I� 1 ' _ _�
<br />onset to death
<br />{
<br />on fine a. DUE TO, OR AS A CONSEQU
<br />Enter the UNDERLYING CAUSE e) J ee io
<br />(disease or injury that initiated �6 '
<br />onset to death
<br />the events resattlng In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST �j� /���
<br />d) W 011 43 Ib del t
<br />onset to death
<br />16. P OTHER SKGNI IO s co
<br />CONDITNS orntdbtltng tot's* the underlying cape given In PART I.
<br />n � /]/ y s ��',�y^�sy,,.,I,� ��.r{/,�'J� , 111PPaltha19 but not resulting In
<br />' ! 1°t. 4r � UU �11 �I.1 t�. 1 Vli Ptiti DI SthC HMI v 1/'/ , tc. &Pit 01 f(A'JA--
<br />16. WAS MEDICAL EXAMINER
<br />OR CORONER ACTED?
<br />❑ YES NO
<br />MI• IF FEMALL
<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 ❑ Homldde
<br />❑ Accident ❑ Could not t be det atlon
<br />❑ Suicide ❑Could not bs datamdned
<br />21b. IF TRANSPOR2'ATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY ORMED?
<br />e A
<br />❑YES Qi NO
<br />+�
<br />21d. WERE AUTOPSY CAUSE 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 />m
<br />22c. PLACE OF INJURY -At home, ferns, street, factory, office building, construction eke. etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF awJURY. S R*T /,IRUMBER, APT. NO. CITY/TOWN STATE VP CODE
<br />y�r
<br />DATE OF DEATH 050.0 7119. Yr4 "
<br />B' *
<br />,
<br />' 3
<br />z
<br />5
<br />1
<br />I �, a z
<br />G
<br />8
<br />kO O Cif
<br />TISSUE DONATION
<br />ill NO
<br />19112
<br />24a. DATE SIGNED (Ma, Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />-
<br />. ..
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />23d To of my , death o(� at the
<br />due _' _ ,! ' , ` (Sign a and Toe)
<br />i i f, / �/•
<br />• «•
<br />i�ctr, rese w at 1 ' " �- ' '' a ` • � ,
<br />ADDRESS OF C `... I t ' r M (Type or Print)
<br />time, • and place
<br />26e. HAS ORGAN OR
<br />. ❑ YES
<br />Lioi J
<br />24e. On the basis of examination
<br />at tits tine, date and place
<br />BEEN CONSIDERED?
<br />&ai
<br />andlor investigation, In my opinion death occurred
<br />and due to the cause(*) stated. (Signature and Title)
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable N 26a is NO ❑ YES ❑ NO
<br />/ If VI
<br />2Be. RlOp8TRAR S SIOBATURE .rmmhitio
<br />p si
<br />211b. DATE FILED BY REGISTRAR (Ma, Day, Yr.)
<br />NOV 19 2015
<br />2015 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />This certifies this document to be a true copy of an original record on file with Vital Statistics, Douglas
<br />County Health Dept., Omaha, Nebraska. Certified copies must have a raised seal in the area to the left.
<br />Reproduction of this green certificate are not legal copies.
<br />Cote'
<br />Issued: N 0 V 19 2015 Registrar: " Gel
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