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To be completed by: CERTIFIER I I To be completed/verified by: FUNERAL DIRECTOR I McComb Mlddle, Last, Suffix) 1 James Dale ME z. Male ; ..�'' � Jan€il�ry 23� 20M4, Day, Yr.) 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Coin, Iowa 5a. AGE - Last Birthday (Yrs.) 77 5b. UNDER 1 YEAR 5c. UNDER 1 DAY i , 6. DATE OF BIRTH (Mo., Day, Yr.) ', June 26, 1936 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -38 -5721 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Home ❑ DOA ❑ Other (Specify) 8b. FACILITY -NAME (If not Institution, give street and number) 316 Comanche Avenue 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 316 Comanche Avenue e. APT. NO. 8f. ZIP CODE I 68803 9g. INSIDE CITY LIMITS IA 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 Bette Jean Millspaugh 11. FATHER'S -NAME (First, Middle, Last, Suffix) Raymond McComb 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Frances Searle 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Bette Jean McComb 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.) January 23, 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) 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 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: onset to death IMMEDIATE t:AUSE (Final a) Respiratory Failure Minutes disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death Sequentially list conditions, if b) Myocardial Infarction I Minutes any, leading to the cause listed 1 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: i onset to death Enter the UNDERLYING CAUSE C) 1 (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) ■ 1 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Chronic History Of Heart Problems, Diabetes And Lung Cancer 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 ❑ Ho, ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be deterrnined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE w s r z 23a. DATE OF DEATH (Mo., Day, Yr.) I To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) January 27, 2014 24b. TIME OF DEATH Approx. 02:30 AM 23b. DATE SIGNED (Mo., Day, Yr.) 1 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) January 23, 2014 24d. TIME PRONOUNCED DEAD 02:59 AM Si g .6 O 3d. To the best of my knowledge, death occurred at the time, date and place G and due to the cause(s) stated. (Signature and Title) o c2 ii , 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) Jon Hendricks, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN 26a. HAS ORGAN OR ❑ YES SSUE DO 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 Jon Hendricks, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 r 28a. REGISTRAR'S SIGNATURE JAS - 1 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) January 28, 2014 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH A, AC&sumio SEFWI( S,» JT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA "D','E, ET V HEALtH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR UlTAL REC2jR4'S' ° f a DATE OF ISSUANCE 01/30/2014 STANLEY S. CO(1 • f 4 ASSISTANT Sr TE?RE ISTRAP' D, DARTMEN OF f1a4LTH ANL� LINCOLN, NEBRASKA FAAAN,SERVICES ` • a STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SEI4VIC68 ° "'r. CERTIFICATE OF DEATH � F `)�, 14 00359