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STATE OF NEBRASKA 201704489
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />AUG 0 8 2007
<br />LINCOLN, NEBRASKA
<br />CERTIFICATE OF DEATH
<br />TANLEYS. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />HEALTH AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUP ©7 2847
<br />1. DECEDENT'S -NAME (First,
<br />Carl
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Arcadia, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508 -28 -9501
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />St. Francis Medical Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />410 Amick Avenue
<br />10a. MARITAL STATUS AT TIME OF DEATH Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle,
<br />Fred V.
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes.
<br />(Yes, no, or unk.) Yes
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑ Donation
<br />Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City or Town, State) 1225 North Elm Avenue
<br />Livingston - Butler - Volland Funeral Home Hastings, Nebraska
<br />IMMEDIATE CAUSE (Final
<br />disease or conditlon resulting
<br />in death)
<br />Sequentially list conditions, N
<br />any, leading to the cause listed
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury that Initiated
<br />the events resulting in death)
<br />LIST
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />28a. REGISTRAR'S SIGNATURE
<br />DUE T0, OR AS A CONSEQUENCE OF:
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(c)
<br />(d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Mc
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />9b. COUNTY
<br />Hall
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant,'but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />22a. DATE OF INJURY (Mol Da , Yr.)
<br />Middle,
<br />R
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />16a. EMBALMER- SIGNATURE
<br />No Embalming
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />22b. TIME OF INJURY
<br />m
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 1, 2007
<br />23c.TIME OF DEATH
<br />5:20 a m
<br />Last,
<br />Amick
<br />5a. AGE -Last Birthday
<br />(Yrs.) 79
<br />Last, Suffix)
<br />Amick Dr.
<br />Suffix)
<br />5b. UNDER 1 YEAR
<br />MOS. DAYS
<br />9e. APT. NO
<br />2. SEX
<br />Male
<br />50. UNDER 1 DAY
<br />HOURS MINS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL:
<br />a Inpatient
<br />❑ ER /Outpatient
<br />❑ D34
<br />❑ Nursing Home/LTC ❑ Hospice Facility
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />9c. CITY OR TOWN
<br />Doniphan
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9f. ZIP CODE
<br />68832
<br />14a. INFORMANT -NAME
<br />Renee J. Amick
<br />16b. LICENSE N0.
<br />18. PART 1. Enter the chain of events -- diseases, injuries, or complications- -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary.
<br />IMMEDIATE CAUSE:
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 1, 2007
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />December 3, 1927
<br />9g. INSIDE CITY LIMITS
<br />OYES NO
<br />105. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Renee J. Youngson
<br />12. MOTHER'S -NAME (First,
<br />Lillian
<br />Middle
<br />R.
<br />Maiden Surname)
<br />Rydberg
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16c. DATE (Mo., Day, Yr. )
<br />August 1, 2007
<br />BV Cremation Center
<br />CITY / TOWN
<br />STATE
<br />Hastings Nebraska
<br />175. Zip Code
<br />68901
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />onset to death
<br />onset to death
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES /K610
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />\t.) 14i
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />STATE ZIP CODE
<br />24b.TIME OF DEATH
<br />m
<br />24d. TIME PRONOUNCED DEAD
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr,)
<br />AUG 7 2007
<br />m
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />❑ YES ❑ NO ❑ PROBABLY )B UNKNOWN ❑ YES NO Not Applicable if 26a is NO ❑ YES gr NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Steven L. Husen, M.D., 2116 W. Faidley Ave. Suite 400, Grand Island, NE 6880
<br />
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