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To be completed/verified by: FUNERAL DIRECTOR 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Frankie Garth Elliott 2. SEX, , t A Male iffItIME ORDEAT,ffilo., Day,. Yr.) `.,August~2S'2011` 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Red Cloud, Nebraska 5a. AGE - Last Birthday (Yrs.) 73 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.). March 22, 1938 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -38 -7056 8a. PLACE OF DEATH J•IOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Fac)Iity 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center ❑ ER/Outpatlent ❑ Decedent's Home ❑ 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 2508 Pioneer Blvd 9e. APT. NO. I 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 Virginia Joyce Brown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Francis Gilbert Elliott 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Blanche Ella Fair 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 12/07/1956- 11/14/1957 14a. INFORMANT -NAME Virginia Joyce Elliott 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) September 1, 2011 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery 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 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 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 onset to death 3 Days respiratory arrest, or ventricular fibrillation without Showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Inc. l Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death sequentially list conditions, if b) Lung Carcinoma With Metastases Brain 2 Months any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Smoking (disease or Injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Atrial Fibrillation With Rapid Ventricular Rate 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 ❑ 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 ® NO 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 ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE S w 1 E ,_ g u z 23a. DATE OF DEATH (Mo., Day, Yr.) August 28, 2011 E' �g i u ). > 4 . 2 . k } E o.< 21 s W 0 a p U ~ 0 o 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) A 30, 2011 23c. TIME OF DEATH 11:59 AM 24c. PRONOUNCED DEAD (Mo., pay, Yr.) 24d. TIME PRONOUNCED DEAD 0 ` e ' < 3 d. To the beat o f my knowla.Jge, loath occurred at tha time, date and place $ C and due to the causes) stated. (Signatu nd Title) s William Landis, MD 240, On the baste of examina[IO11 end /or Investigatidn, in my opinion death occurretl at the time, date and place and due to the causes) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 1 26a. HAS ORGAN OR ❑ YES DONATION BEEN CONSIDERED? 11 • 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO 0 YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, William Landis, MD, 2444 W. Faidley Avenue, HYSICIAN ASSISTANT PHYSICIAN OR COUNTY A Grand Island, Nebraska, •: 03 TORNEY) (Type or Print) r 1 285. REGISTRAR'S SIGNATURE /)rte A- 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) September 1, 2011 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 NEBRA4SK4, OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VV4}4I RDS DATE OF ISSUANCE 09/06/2011 STATE OF NEBRASKA 201705945 ST Let' it OPER AS igrANT DEPlaRTMEN `n'E LINCOLN, NEBRASKA - HUAV ER,J'CES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN 'SERVIt FS * CERTIFICATE OF DEATH 4 t `Pi r . ...