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To be completed/verified by: FUNERAL DIRECTOR I
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix) 2
<br />2. SEX 3
<br />3. DATE OF,DIEATH.(Iflo., 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 6
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />MOS. D
<br />DAYS H
<br />HOURS M
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER 8
<br />8a. PLACE OF DEATH
<br />8b. FACILITY -NAME (If not Institution, give street and number) 0
<br />0 ER/Outpatient ❑ Decedent's Home
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) S
<br />Sd. COUNTY OF DEATH
<br />9a. RESIDENCE -STATE 9
<br />9b. COUNTY 9
<br />9c. CITY OR TOWN
<br />9d. 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 (Nlo., Day, Yr.)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 1
<br />17b. Zip Code
<br />CAUSE OF DEATH (See instructions and examples)
<br />I To be completed by: CERTIFIER
<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, A
<br />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: o
<br />in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Sequentially list conditions, if b) Sepsis
<br />any, leading to the cause listed
<br />on l
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset t0 death
<br />LAST d)Atrial Fibrillation
<br />18. PART 11. 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 />22d. INJURY AT WORK? 2
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />B W S
<br />23a. DATE OF DEATH (Mo., Day, Yr.) }
<br />} 2
<br />24a. DATE SIGNED (Mo., Day, Yr.) 2
<br />24b. TIME OF DEATH
<br />2 3b. DATE SIGNED (Mo., Day, Yr.) 2
<br />23c. TIME OF DEATH =
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 2
<br />24d. TIME PRONOUNCED DEAD
<br />3 g 0 . 'c the best of my knowledge, death occurred at the time, date and place w
<br />24e. On the basis of examination and/or Investigation, in my opinion death h occurred
<br />2 1,7
<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 NEBRASKA, AA7 t QF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR AVAL RD 1 -, ; I
<br />DATE OF ISSUANCE
<br />12/17/2012
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />STM:itgY S., COOPER , ,
<br />ASSISTANT ,STATE
<br />DFPARrME 6F /4 1.11/ 'AND ',
<br />HUMpMV, SE ICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES '•
<br />CERTIFICATE OF DEATH
<br />12 03462
<br />
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