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To be completed by: CERTIFIER 1 1 To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) 2 2. SEX 3 3. DATEOF'DEAFH Day, Yr.) 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5 5a. AGE - Last Birthday 5 5b. UNDER 1 YEAR 5 5c. UNDER 1 DAY 6 6. DATE OF BIRTH (Mo., Day, Yr.) (Yrs.) M MOS. D DAYS H HOURS P PAINS. SOCIAL SECURITY NUMBER 8 8a. PLACE OF DEATH ❑ ER/Outpatient ❑ Decedent's Home 8b. FACILITY -NAME (If not Institution, give street and number) ❑ 8d. COUNTY OF DEATH 9a. RESIDENCE -STATE 9 9b. COUNTY 9 9c. CITY OR TOWN 9d. STREET AND NUMBER 9 9e. APT. NO. 19f. Z ZIP CODE 9 9g. INSIDE CITY LIMITS 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 1 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name 11. FATHERS-NAME (First, Middle, Last, Suffix) 1 12. MOTHER'S -NAME (First, Middle, Maiden Surname) 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 1 14a. INFORMANT -NAME 1 14b, RELATIONSHIP TO DECEDENT 15. METHOD OF DISPOSITION 1 16a. EMBALMER- SIGNATURE 1 16b. LICENSE NO. 1 16c. DATE (Mo., Day, Yr.) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 1 17b. Zip Code CAUSE OF DEATH (See instructions and examples) r 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 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: onset to death IMMEDIATE CAUSE (Final a) Acute Congestive Heart Failure 1 Month disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, it b) I any, leading to the cause listed � 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 1 d) 1 1 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 1 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 0 N 20. IF FEMALE: 2 21a. MANNER OF DEATH 2 21b. IF TRANSPORTATION INJURY 2 21c. WAS AN AUTOPSY PERFORMED? 21 d. WERE AUTOPSY FINDINGS AVAILABLE 22a. DATE OF INJURY (Mo., Day, Yr.) 2 22b. TIME OF INJURY 2 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? 2 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE a W N 23a. DATE OF DEATH (Mo., Day, Yr.) T To be completed by CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 2 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) 2 23c. TIME OF DEATH 2 3 0 < 23d. To the best of my knowledge, death occurred at the time, date and place 2 24e, On the basis of examination and /or Investigation, in my opinion death occurred at 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR ISSUE DONATION BEEN CONSIDERED? 2 26b. WAS CONSENT GRANTED? 27. NAME, 'TITLE AND ADDRESS OF CERTIFIER (Type or Print Donald Wirth, MD, 2116 W Faidley #400, Box 9802, Grand Island - • a, 68803 C 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 DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.. DATE OF ISSUANCE 12/07/2015 LINCOLN, NEBRASKA STATE OF NEBRASKA 201600146 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S COOPER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEATH ANb HUMAN SERVICES ` t 15 06919