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To Be CompletedNerified by: FUNE ECTOR T. DECEDENTS -NAME (First, Middle, Last, Suffix) Donald Herman Muhs 2. SEX ' Male ` J. DATE OF DEATH (M0.,Day,Yr.) August 28, 2008 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Hall County, Nebraska 5a. AGE -Last Birthday (Yra.) 75 5b. UNDER 1 YEAR 6c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.) January 7, 1933 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -36 -4079 8a. PLACE OF DEATH HOSPITAL' 0 inpatient OTHER:❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center ❑ ER/Outpatient ❑ Decedent's Home 0 DOA ❑ Other(Specify) 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 254 South Plum 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® Yes ❑ No 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Manied, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Sux) If wire, give maiden name. Suffix) Dolores ,Eleanor Stefanowicz 11. FATHER'S -NAME (First, Middle, Last, Suffix) Herman Muhs II 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Hilda Reher 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 02/11/1953- 02/10/1955 14a. INFORMANT -NAME Dolores Muhs 14b. RELATIONSHIP TO DECEDENT Spouse 16. METHOD OF DISPOSITION ®Berla1 ❑D °real °° ❑Cromation ❑Entomemant ❑Remowl ❑Other(Spaciry) 16a. EMBALMKSIGNATURE ( 16b. LICENSE NO. /39 7 16c. DATE (Mo., Day, Yr.) September 2, 2008 16d EMET RY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE Westlawn Memorial Park Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 To Be Completed by: CERTIFIER CAUSE OF DEATH (See instructions and examples) 1a. PART 1. Enter the L/00 of eventa - diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, 1 APPROXIMATE INTERVAL respiratory east, or ventricular fibrillation without slowing the etiology. DO NOT ABBREVIATE Enter only one cause on a line. Add additional lines R necessary. IMMEDIATE CAUSE: f i onset to death IMMEDIATE CAUSE (Final Il e CL -In (� ( .. 0 rr_, disease or condition resulting a) � in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death 1 I Sequentially list conditions, if 1 e ct 1 '-- �."�_ . ��lk�w c b) Y4 fv any, leading to the cause listed on line S. DUE TO, OR AS A CONSEQUENCE OF: I onset to death I Enter the UNDERLYING CAUSE c) I (disease or Injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: - i onset to death LAST I d) I 18. PART II. OTHER SIGNIFICANT CONDITIONS- Condidons contributing to the d but not resulting In the underlying cause given In PART!. ea (1 t I n SO h , S (»VA. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES [ RO 20. IF FEMALE: CI 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 store/ ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES U N 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22.. 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 8 NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE 2 a5 V } r Eaz �o 3 2'2 23a. DATE OF DEATH (Mo., Day, Yr.) August 28, 2008 Z .0 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH m 23b. DATE SIGNED (Mo., Day, Yr.) 9• 2 ^Z.one 23c. TIME OF DEATH 2:3 p m y 0 Et. 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD m 23d. To the beet of my knowledge, th occurred at the t date and place and due to e c (a) stat . ignature and Title) 0 W z 0 , 58 vo 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) 25. DID TOBACCO USE CONTRIBUTE TO THE D •�• TH? ❑ YES NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES .NO 26b. WAS CONSENT GRANTED? Not Applicable H 26a is NO ❑ YES , NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Gary Settje M.De, 2116 W. Faidley Ave., Grand Island, Nebraska 68803 P 28a. REGISTRAR'S SIGNATURE 4 . • , 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) SEP 9 2008 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE 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 FO�Z'tIITA4 RECORDS. STAlyLEY S. COOPER ASSt$$ STATE REGISTRAR DEPARTMENT OF FIEALT AND .; f(JMAN SERVICES DATE OF ISSUANCE SEP 10 2008 LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERV),CES " ffi CERTIFICATE OF D -W $. , 118 STATE OF NEBRASKA 201701689