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<br />2 SEX
<br />3. DATE OF DEATH /MOnfn Day. vearl
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<br />Male
<br />March 25, 2000
<br />4 CITY AND STATE OF BIRTH ,lt nol m USA. name counfryl
<br />Sa. AGE - Last Binhday
<br />UNDER I YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month. Day year) `
<br />Central City, Nebraska
<br />(Y's1 82
<br />April 16, 1917
<br />5b MOS ; DAYS
<br />Sc.HOURS MINS
<br />7 SOCIAL SECURTIY NUMBER
<br />8a PLACE OF DEATH -
<br />507 16 4857
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<br />WHEN THIS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND
<br />SYSTEM, IIT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REC
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _
<br />DATE OF ISSUANCE �,0 � � � � � O �I, �(f (,�YIU
<br />APR 2 12000 ' b ASSISTA,
<br />LINCOLN, NEBRASKA HEALTH AND HUMi
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SER
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH
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<br />t DECEDENT - NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3. DATE OF DEATH /MOnfn Day. vearl
<br />Dale Neil McMillan
<br />Male
<br />March 25, 2000
<br />4 CITY AND STATE OF BIRTH ,lt nol m USA. name counfryl
<br />Sa. AGE - Last Binhday
<br />UNDER I YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month. Day year) `
<br />Central City, Nebraska
<br />(Y's1 82
<br />April 16, 1917
<br />5b MOS ; DAYS
<br />Sc.HOURS MINS
<br />7 SOCIAL SECURTIY NUMBER
<br />8a PLACE OF DEATH -
<br />507 16 4857
<br />HOSPITAL F] Inpatient OTHER Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />8b FACILITY - Name (lt not'nshfufion, give sheet and number)
<br />VAGNHCS 2201 North Broadwell
<br />❑ DOA ❑ Other 'Spec,ty,
<br />8c CITY. TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island, Nebraska Yes 0 No ❑
<br />Hall
<br />9a RESIDENCE - STATE
<br />9 COUNTY
<br />9c CITY. TOWN ORS
<br />9d. STREET AND NUMBER pncloo ft
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1760 South Arhur
<br />Yes ® No ❑
<br />10 RACE - (e g, White. Black. American Indian
<br />11. ANCESTRY le .g.. Italian. Mexican. German, etcl
<br />12. n MARRIED ❑ WIDOWED
<br />73 NAME OF SPOUSE pt wife give maiden name)
<br />etc 11SOectryl White
<br />(SOeaty) Scotch, Irish
<br />NEVER DIVORCED
<br />Norma Jean Fishhurn
<br />14a USUAL OCCUPATION IG,ve k,rd of work done during most
<br />14b KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION (Specify only highest grade completed)
<br />of working life even if lehredl
<br />Real Estate Broker, Ret.
<br />Commercial Real Estate
<br />Elementary or Secondary 10 -12) College I1 -4 or 5.1
<br />12th
<br />16 FATHER -NAME FIRST MIDDLE LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />(Dec.) Hubert Neil McMillan
<br />(Dec.) Mary L. Reeves
<br />18 WAS DECEASED EVER IN L ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />Yes n° nrnnk, I WWI1vc °°a1a�716%425� 2/9/46
<br />Norma J. McMillan
<br />,�� ,nrvmm�n, mnlunu nvvncJJ IJ, mccl um n.r.0 nlu.. ul,T um lu- ii Hi c. 4irl
<br />1760 Sourth Arthur Street, Grand Island Nebraska 68803 _
<br />20. MER - SIGNAt ICENS 21a. METHOD OF DISPOSITION �lb . DATE 121c. CEMETERY OR CREMATORY NAME
<br />/ EBurial Removal arch 28,200 Chapman Cemetery
<br />a FUNERAL HOME - NAME. 21 of CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />jAll Faiths Funeral Home ❑Cremation ❑Donator, Chapman Cemetery Chapman NE.
<br />22b FUNERAL HOME ADDRESS SSTREET OR R.F D. NO CITY OR TOWN. STATE, ZIP)
<br />2929 S. Locust St. Grand Island, NE. 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR 1aI. (bl. AND (c)) Interval between onset and dean
<br />PART I
<br />I(a) Coronary artery disease, Congestive heart failure 6 years _
<br />DUE TO, OR AS A CONSEOUENCE OF I Interval between onset and death
<br />(bi Chronic obstructive pulmonary diseas_ e `. 10 years.+
<br />D:1L: TO. 0. AS A CJIVSEJJENCE OF I Interval between onset and deam
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<br />OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY
<br />PART PREGNANCY IN THE PAST 3 MONTHS
<br />II
<br />(Ages 10 -54) Yes No Yes No
<br />26a 261) DATE OF INJURY (Mo.. Day. Yr./ 26c. HOUR OF INJURY 26d. DESCq'' E HOW INJURY OCCURRED
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER'
<br />( 1
<br />Yes I I No FYI
<br />Accident F] Untlelermmed
<br />M
<br />Suicide ❑ Pending
<br />26e INJURY AT WORK
<br />26f PLLACE OF INJURY - At home. farm. street. factory
<br />-
<br />26g. LOCATION STREET OR R.F.D. NO, CITY OR TOWN STATF
<br />Homicide Investgauon
<br />Yes ❑ ❑
<br />o8,ce building. etc ,Specify)
<br />No
<br />27a. DATE OF DEATH No Day. Yr/ I
<br />28a. DATE SIGNED (Mo. Day. Yrl
<br />28b. TIME OF DEATH
<br />=
<br />March 25, 2000
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<br />27b. DATE SIGNED (Mo. Day Yr)
<br />27c TIME OF DEATH
<br />28c. PRONOUNCED DEAD IMo. Day. Yr)
<br />28d. PRONOUNCED DEAD (Noun
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<br />March 28, 2P90
<br />10:00 aM
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<br />27d. To the best of my knowledg ath occurred at the time, date and place and due to the
<br />28e. On the basis of examination and or mveshgatton, in my opinion death occurred at
<br />9 °
<br />causelsl stated.
<br />° _
<br />the time, date and place and due to the causes) stated.
<br />29 DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30A HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 30.b WAS CONSENT GRANTED'(
<br />❑ YES 1:1 NO ® UNKNOWN ❑ YES 1.:0 NO ❑ YES ® NO
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEYI (Type or Pimp
<br />Ghulam R. Mirza, M.D., VAGNHCS 2201 North Broadwell, Grand Island, Nebraska 68803
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