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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Mark Dudley Nelson . $ Vr Mile,` i' ? ; 3. DATEQF DEATH (Mo.; Day, Yr.) 1 Jurie 26 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Minneapolis, Minnesota 5a. AGE - Last Birthday (Yrs.) 67 6b. UNDER 1 YEAR 5c. UNDER.tpAY. ., 6, DATE OF BIRTH (Mo., Day, Yr.) December 28, 1947 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 475 -54 -6974 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 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 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 3124 Goldenrod Dr. 9e. APT. NO. 9f. ZIP CODE I 68801 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 Susan Lynn Eye 11. FATHER'S -NAME (First, Middle, Last, Suffix) Dudley Nelson 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Priscilla Sargent 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or unk.) Yes 11/28/1967- 12/23/1969 14a. INFORMANT -NAME Susan Lynn Nelson 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) June 26, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 U To be completed by: CERTIFIER CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events- -diseases, injuries, or complications•thatrlirectly 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 11 necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Unknown Natural Causes disease or condition resulting onset to death Minutes in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) any, leading to the cause listed online 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: I onset to death LAST d) I 1 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Diabetes, Hypertension, Chronic Obstructive Pulmonary Disease, Pulmonary Edema 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF 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 if pregnant within the past year 21a. MANNER OF DEATH ID Natural 0 Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be deterrnined 21b. IF TRANSPORTATION INJURY ❑ OriverlOperator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21e. 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 .2 6 1 F E z 23a. DATE OF DEATH (Mo., Day, Yr.) To be completed by CORONER'S PHYSICIAN of COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) June 29, 2015 24b. TIME OF DEATH Approx. 11:22 AM 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) June 25, 2015 24d. TIME PRONOUNCED DEAD ' 11:40 AM g u 0 3d. To the best of my knowledge, death occurred at the time, date and place S and due to the cause(s) stated. (Signature and Title) 12 li 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Sarah Hinrichs, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN ❑ YES 17 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Sarah Hinrichs, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 28a. REGISTRAR'S SIGNATURE A - 1 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) July 1, 2015 DATE OF ISSUANCE 07/06/2015 LINCOLN, NEBRASKA STATE OF NEBRASKA 201508824 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 NEBRASWERARTIVENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR WTAt t RECO D 1 . COOPER" A9SJSTANT 7ATFs, REGISTRIAO, FOR IT HfALTH, , Nor I1UMAM ERVI I . STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMA4 S kVICS CERTIFICATE OF DEATH t yr 15 03795