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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Marvin Dwaine Person 2. SEX ' Male 3 DATE OF DEATH (Mo., Day, Yr.) November 28, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH south of Marquette, Nebraska 5a. AGE - Last Birthday (Yrs•) 84 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) August 3, 1930 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -34 -6580 8b. FACILITY -NAME (If not Institution, give street and number) 110 West 18th St. 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 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 110 West 18th St. e. APT. NO. r 9f. ZIP CODE I 68801 8g. 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 Betty Jean Land 11. FATHER'S -NAME (First, Middle, Last, Suffix) Axel Person 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Esther Andersen 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 01/10/1952-12/12/1953 14a. INFORMANT -NAME Betty Jean Person 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.) December 1, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon 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 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, r 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) Undetermined Natural Causes disease or condition resulting onset to death in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) I any, leading to the cause listed I I on tine 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: • onset to death LAST d) 1 1 1 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given In PART I. 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 ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ suicide ❑ Could rmined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE . 6 i F E ° W J t) z 23a. DATE OF DEATH (Mo., Day, Yr.) To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) December 2, 2014 24b. TIME OF DEATH Approx. 07:00 AM 23b. DATE SIGNED (Mo., Day, Yr.) J 1 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) November 28, 2014 24d. TIME PRONOUNCED DEAD 09:24 AM S g V 0 3d. Tc the best of my knnwledge, death o,rurred at the time, date and place c and due to the cause(s) stated. (Signature and Title) 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) Tara Nagel, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE r • ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN ❑ YES El NO ATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Tara Nagel, Hall Deputy County Attorney, 231 S. Locust, P.O. Bo 367, Grand Island, Nebraska, 68802 I28a. REGISTRARS SIGNATURE A 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 8, 2014 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL,TIkiANDA11 N,JAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAS�( / 4 DfR,w/0 NT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOP ,VWAL, RECO.l DS -r -- • � >� ii DATE OF ISSUANCE 12/10/2014 LINCOLN, NEBRASKA STATE OF NEBRASKA CERTIFICATE OF DEATH 201602275 STANLEY S COOPER A, `.5SISt4N TAT REGSTRAIR DEPARW4 NT'O# I4 ALTH AND IN hMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 14 06258