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1 7.
<br />To be completed by: CERTIFIER I I To be completed/verified by: FUNERAL DIRECTOR
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Ronald Gene White
<br />2. ' SEX +`•,r :
<br />Male ' 1 ' f'
<br />:3. DEI4TH (Mo.; Day, Yr.)
<br />a September 22, 2015
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Minden, Nebraska
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER1 DAY'
<br />.62-DAT OF BIRTH (Mo., Day, Yr.)
<br />June 17,1957
<br />(Yrs.)
<br />58
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />SOCIAL SECURITY NUMBER
<br />506 -88 -6565
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC 0 Hospice Facility
<br />❑ ER/Outpatient ® Decedent's Home
<br />❑ DOA ❑ Other (Specify)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />4046 Edna Drive
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />4046 Edna Drive
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Lynnette Mary Tenopir
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Eugene Oliver White
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Mary-Anne Drawbridge
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />148. INFORMANT -NAME
<br />Lynnette Mary White
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />El Burial ❑ Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. EMBALMER - SIGNATURE
<br />Laurie D. Sheffield
<br />16b. LICENSE NO.
<br />1397
<br />16c. DATE (Mo., Day, Yr.)
<br />September 28, 2015
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Hillside Cemetery North Loup Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the _hain of events - diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Final a) Metastatic Colorectal Adenocarcinoma 5 Years
<br />disease or condition resulting
<br />in death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death
<br />Sequentially list conditions, it b) I
<br />any, leading to the cause listed I
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />Enter the UNDERLYING CAUSE c) I
<br />(disease or injury that Initiated !
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />LAST 1
<br />d) 1
<br />1
<br />8. PART I I . OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death ' . not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />0. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be deterrnined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ DdverlOperator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES 0 N
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 22, 2015
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />September 23, 2015
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<br />23c. TIME OF DEATH
<br />12:05 PM
<br />1 2 3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Ryan D. Crouch, DO
<br />24e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR
<br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES
<br />ISSUE DONATION BEEN CONSIDERED?
<br />El NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68
<br />I 288. REGISTRAR'S SIGNATURE � ' �
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />September 29, 2015
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASIS DEPARITMNT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR (I7T/ L RECORQS.
<br />DATE OF ISSUANCE
<br />10/02/2015
<br />STATE OF NEBRASKA
<br />201602524
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SET VICES
<br />CERTIFICATE OF DEATH ,� f;
<br />STANLEY S COOPER -.
<br />ASSISTANTSfiA' E REGI -Ag
<br />OEPARTNEIVZ Of„ H ALTK 'ID, A
<br />LINCOLN, NEBRASKA HUAJAN" lr'IC � / : •
<br />1 05635
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