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To be completed by: CERTIFIER 1 1 To be completed /verified by: FUNERAL DIRECTOR 1
<br />1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2
<br />2. SEX . a
<br />a.DATE OP DEATH (Mo., Day, Yr.)
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5
<br />5a. AGE - Last Birthday 5
<br />5b. UNDER 1 YEAR 5
<br />5c. UNDER 1 DAY .
<br />., 5-DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yrs.) M
<br />MOS. D
<br />DAYS H
<br />HOURS M
<br />MINS.
<br />November 8, 1923
<br />7. SOCIAL SECURITY NUMBER 8
<br />8a. PLACE OF DEATH /
<br />® ER/Outpatient ❑ Decedent's Home
<br />8b. FACILITY -NAME (If not Institution, give street and number) ®
<br />8d. COUNTY OF DEATH
<br />9a. RESIDENCE -STATE 9
<br />9b. COUNTY 9
<br />9c. CITY OR TOWN
<br />STREET AND NUMBER 9
<br />9e. APT. NO. 9
<br />9f. ZIP CODE 9
<br />9g. INSIDE CITY LIMITS
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 1
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 1
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 1
<br />14a. INFORMANT -NAME 1
<br />14b. RELATIONSHIP TO DECEDENT
<br />15. METHOD OF DISPOSITION 1
<br />16a. EMBALMER - SIGNATURE 1
<br />16b. LICENSE NO. 1
<br />16c. DATE (Mo., Day, Yr.)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) 1
<br />17b. Zip Code
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain 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) PEA Arrest Hours
<br />disease m cnr�.d .suiting
<br />M death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />Sequentially list conditions, it b) Cardiac Arrest 1
<br />1
<br />any, leading to the cause listed
<br />I
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />Enter the UNDERLYING CAUSE c) 1
<br />(disease or injury that initiated 1
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />LAST i
<br />d) 1
<br />1
<br />18. PART II, OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 1
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ NO
<br />20. IF FEMALE: 2
<br />21a. MANNER OF DEATH 2
<br />21b. IF TRANSPORTATION INJURY 2
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 2
<br />22b. TIME OF INJURY 2
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />Home
<br />22d. INJURY AT WORK? 2
<br />22e, DESCRIBE HOW INJURY OCCURRED
<br />Patient brought in by ambulance on 12/25/2016 after he had an unwitnessed event. He was in PEA arrest upon arrival of
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />319 E 17th St, Grand Island Nebraska 68801
<br />� � I23a. DATE OF DEATH (Mo., Day, Yr.) T
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a, DATE SIGNED (Mo., Day, Yr.) 2
<br />24b. TIME OF DEATH
<br />i F 23b. DATE SIGNED (Mo., Day, Yr.) 2
<br />23c. TIME OF DEATH 2
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr. 2
<br />24d. TIME PRONOUNCED DEAD
<br />g O
<br />24e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 2
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 2
<br />26b. WAS CONSENT GRANTED?
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Danielle L. Myers, Hall Deputy County Attorney, 2
<br />231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />P
<br />DATE OF ISSUANCE
<br />01/06/2016
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<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 NEBRASKAJAW MENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL WORDS :,
<br />20160765x;
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />STANLEY S. COOPER '. ' .
<br />ASSISTANTSTATEREGISTRAR
<br />DEPARTMENTT OF, HEALTH AND
<br />H.VMAN SER (ICES
<br />f "
<br />15 07498
<br />
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