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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Michael Cooper Erickson 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) November 15, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Concordia, Kansas 5a. AGE - Last Birthday (Yrs.) 66 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) January 23, 1947 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 513-42-1365 8b. FACILITY -NAME (If not Institution, give street and number) 1619 Coventry Lane 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ®Decedent's Home ❑ DOA ❑ Other (Specify) Sc. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1619 Coventry Lane e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® 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 Lori Beth Alexander 11. FATHER'S -NAME (First, Middle, Last, Suffix) Leo Erickson 12. MOTHER'S -NAME (First, Middle, Maiden Sumame) Barbara Cooper 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Lori Beth Erickson 14b. RELATIONSHIP TO DECEDENT Spouse 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.) November 18, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I 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) To be completed by: CERTIFIER 18. PART I. Enter the chain of events -- diseases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, r 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: IMMEDIATE CAUSE (Final a) Natural Causes disease or r',n .ition resulting onset to death in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death sequentially list conditions, if b) I any, leading to the cause listed I t line on a. DUE TO, OR AS A CONSEQUENCE OF: i onset to death Enter the UNDERLYING CAUSE c ) I (disease or injury that initiated ; the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) I 1 18 PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 20.1F FEMALE: 3 Not pregnant within past year J Pregnant at time of death 0 Not pregnant, but pregnant within 42 days of death J Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending investigation ❑ suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 0 N 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) r To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) November 18, 2013 24b. TIME OF DEATH Approx. 11:00 AM 23b ". DATE SIGNED (Mo., Day, Yr.) 123c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) November 15, 2013 24d. TIME PRONOUNCED DEAD 11:55 AM Sd. To the best of my knowledge, death occurred at the time, date and place and due to the causes) stated. (Signature and Title) 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cau e(s) stated. (Signature and Title) Jack Zitterkopf, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR ISSUE r • ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN ❑ YES 0 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 Jack Zitterkopf, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 1 28a. REGISTRAR'S SIGNATURE _ ! 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) November 19, 2013 DATE OF ISSUANCE 11/21/2013 LINCOLN, NEBRASKA STATE OF NEBRASKA 201704451 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 FOR VIT4L RkaORDS: STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S COQPE ASSISTANT STATE REGISTRAR DEPARTMET HEALTH AND HUMAN .SE V ` 13 04960