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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. DATE OF DEATH (Mo., Day, Yr.) 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5 5a. AGE - Last Birthday 6 6b. UNDER 1 YEAR 5 5c. UNDER 1 DAY 6 6. DATE OF BIRTH (Mo., Day, Yr.) (Yrs.) M MOS. D DAYS H HOURS M MINS. 7. 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. 9 9f. 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. FATHER'S -NAME (First, Middle, Last, Suffix) 1 12. MOTHER'S -NAME (First, Middle, Maiden Sumame) 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 MA LING ADDRESS (Street, City or Town, State) 1 17b. Zip Code CAUSE OF DEATH See instructions and exam • les 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, A APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Tines N necessary. IMMEDIATE CAUSE: o n death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b) Pneumonia /sepsis 1 10 Days any, leading to the cause listed 1 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) I 1 (disease or Injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST I d) 1 1 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given In PART 1. 1 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? 20. IF FEMALE: 2 21a. MANNER OF DEATH 2 21b. IF TRANSPORTATION INJURY 2 21c. WAS AN AUTOPSY PERFORMED? 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 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 W O 23a. DATE OF DEATH (Mo., Day, Yr.) Y Y 2 24a. DATE SIGNED (Mo., Day, Yr.) 2 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) 2 23c. TIME OF DEATH i o u < 0 2 24e. On the basis of examination and/or Investigation, In my opinion death occurred at 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 2 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 2 26b. WAS CONSENT GRANTED? 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ryan D. Crouch, DO, 800 N Alpha Street, Grand I Island, Nebraska, 68803 r 1280. REGISTRAR'S SIGNATURE DATE OF ISSUANCE 10/16/2015 LINCOLN, NEBRASKA STATE OF NEBRASKA 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 bERARkhfENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY Fop ` ViTQL'RECORDS. STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 10105 STANLEY S COOPER r = ASSISTANT .STATE_REGISTR R DEPARTM HEALTH AND HUMAN SERVICES 15 05915