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To be completed /verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Irvin Richard Collins Z. SEX " Male ' , -.... ,3C7 OF dEATH ( Mo., 'Day, Yr.) • Juli 2$, 26 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Albion, Nebraska 5a. AGE - Last Birthday (Yrs.) 80 5b. UNDER 1 YEAR 5c. UNDER itifi ' y 6. DAjTE OFBIRTH (Mo., Day, Yr.) , ,,, ,, ,.. 44 '' ,,,'' ' . January 11, 1935 MOS. DAYS HOURS 'MINS, , ,y 7. SOCIAL SECURITY NUMBER 505 -40 -4922 8b. FACILITY -NAME (If not Institution, give street and number) 1003 West 8th Street 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Home ' ❑ D OA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1003 West 8th Street 9e. APT. NO. 9f. ZIP CODE 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 Nancy Marie Shriner 11. FATHER'S -NAME (First, Middle, Last, Suffix) Elmer Collins 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Lucy Hulse 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 02/03/1953 - 01/18/1955 14a. INFORMANT -NAME Nancy Marie Collins 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Laurie D. Sheffield lob. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) July 1, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER r ie. PART I. Enter the chain of events -- diseases, Injuries, or complications -that directly caused the death. DO NOT solar 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: IMMEDIATE CAUSE (Final a) Acute Renal Failure diane00 ur LOn4i.i' ieau:i:.14 onset to death Days in death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death Sequentially list conditions, if b) Multiple Myeloma /plasma Cell Leukemia t Months 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: t 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. COPD, Chronic Diastolic Heart Failure, Anemia, Diabetes, Atrial Fibrillation 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 0 N 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 ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 1X1 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 W EY x � t r E z Zia. DATE OF DEATH (Mo., Day, Yr.) I June 28, 2015 z - I '�� v g 1e E g W s. z O 8 ' g U ~ o 0 24a. GATE SIGNED (Mo., Day. Yr.) 1 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) June 30, 2015 23c. TIME OF DEATH l 05:19 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 < O 3d. To the best of my knowledge, death occurred at the time, date and place 8 o and due to the cause(s) stated. (Signature and Title) 2 Jay C. Anderson, MD 24e. On the basis of examination and/or Investigation, in my opinion death occurred at the time, date and place and due to the cau e(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 1 28a. REGISTRAR'S SIGNATURE A - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) July 1, 2015 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 DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE 07/06/2015 .201600949 $T<YNL *, CodPkif „ t ASSISTANT STATE RI?GIS 1 DkPARTMENt LINCOLN, NEBRASKA HUMAN Fa, IZTTC S t • r r I r STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES " 1 r' 15 03792 CERTIFICATE OF DEATH .• ,, f'