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' rlcta S s.^a�.,.. 1 .� .. � - . n-- , �+�"°�b....,. -.a. °fir -.... .�> s - 0,0 0 iNIPMV) r:r�• !x � P WHEN THIS ' COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT 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 9/6/2016 LINCOLN, NEBRASKA 201606155 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 0 w 0 -J IZ W U u w 1. DECEDENTS -NAME (First, Middle, Last, Suffix) David James McHugh 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 505 -96 -8860 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a; RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 216 E. Ashton Ave 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married E Never Married ❑ Married, but separated ! ❑ Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, NO or Unk.) NO 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation Cremation ❑ Entombment ❑ Removal ❑ Other. (Specify) 20. IF FEMALE: • ❑ Net pregnant within pest year 0 Pregnant at time of death 0 Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant83 days to 1 year before death ❑ Unknewn if pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 2s IN AT:YVORK? YES .0N0::::: 23a. DATE OF DEATH (Mo., Day, Yr.) AU'ttust 29, .2016 s I Jane A McDonald, MD 25. big TOBACCO USE CONTRIBUTE TO THE DEATH? RYES ❑ NO [ PROBABLY ❑ UNKNOWN 55. AGE - Last Birthday (Yrs.) 52 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Not Embalmed 22b. TIME OF INJURY 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH August 30, 2016 02:45 PM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 5b. UNDER 1 YEAR MOS. DAYS 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Qutpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island '9e. APT. NO. 9f. ZIP CODE 68801 lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name 11. FATHER'S-NAME (First, Middle, Last, Suffix) Wilbur McHugh f 12. MOTHER'S -NAME (First, Middle, Therese Connelly Maiden Surname) 14a. INFORMANT -NAME Therese McHugh 16b. LICENSE NO. 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston- Sondermann Funeral Home, 601 N. Webb Road. Grand Island. Nebraska 3. DATE OF DEATH (Mo., Day, Yr.) August 29, 2016 6. DATE OF BIRTH (Mo.,Day, Yr.) August 5, 1964 9g. INSIDE CITY LIMITS YES ❑ NO 14b. RELATIONSHIP TO DECEDENT,: Mother 16c. DATE (Mo., Day, Yr.) August 31, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Memorial Park Cremato ry CITY I TOWN Grand Island STATE Nebraska:` 17b. Zip Code 68803 CAUSE OF DEATH (See instructions and examples) t$, PART t. Enter the -chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventritufer fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE (Final disease or condition resulting in death) ... _.. IMMFDIATE CAUSE: a) Destructive Mass Right scapula, ? Sarcoma - no biopsies performed APPROXIMATE- INTERVAL: onset to death' Several Months DUE TO, OR AS A CONSEQUENCE OF: Sequentially list coitgitions, if ;;b) any, feeding to the Cause listed, .,.,. on line's DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE C) ; (diseaseor iniury :tAat initiated events resuttingin death) DUE TO, OR AS A CONSEQUENCE OF: LAST ` d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Tobacco Use 21b, IF TRANSPORTATION INJURY Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other(Specify) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES END 21c. WAS AN AUTOPSY PERFORM ❑ YES gl NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES Q Na 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET 8, NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 248. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES EI NO 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the causes) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? m Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803 28a, REGISTRAR'S SIGNATU 28b. DATE FILED BY REGISTRAR (MO., Day, Yr.) August 31, 2016