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To Be C:ompletedNerified by: FUNERAL DIRECTOR
<br />1. DECEDENT'S -NAME (Flat, Middle, Last, Suffix)
<br />Ronald Bryce Alexander
<br />2. SEX - " 1
<br />Male
<br />t 3.. DYATEOFDEATH (Mo.,Day,Yr.)
<br />Decembe 17, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />67
<br />Sb. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />June 27, 1944
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />505 -52 -6494 '
<br />no. FACILITY -NAME (if nut institution, give Mimi anu number)
<br />St Elizabeth Regional Medical Center
<br />8a. PLACE OF DEATH
<br />bOSPITAL: ❑x Inpatient OTHER;❑ Nursing Home/LTC ❑ Hospice Facility
<br />v ER /Outpatient ❑Decedent's Home
<br />❑ DOA ❑ Other(Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Lincoln 68510
<br />8d. COUNTY OF DEATH
<br />Lancaster
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1508 N. Hancock
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />® Yes ❑ No
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Eunice Hague
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Raymond J Alexander
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />irene H Scheibe
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) No
<br />14a. INFORMANT -NAME
<br />Eunice Alexander
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />® Buriet ['Donation
<br />❑Cremation ['Entombment
<br />['Removal ❑Other(sl»etty)
<br />16a. EMBALMER - SIGNATURE
<br />'. 0 V �^
<br />-
<br />16b. LICENSE NO.
<br />i 391
<br />16c. DATE (Mo., Day, Yr.)
<br />December 22, 2011
<br />16d. CEMETER , CREMATORY OR OTHER LOCATION CITYITOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />- To Be Completed by: CERTIFIER
<br />CAUSE OF DEATH (See instructions and examples)
<br />is PART I ,over the stele of events • rimes -me. Inlunee or rorepi:esnsne- r.at du'st'y seueen death. Do HOT antes fennlnel events such as cardiac snvs'•
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />ours
<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:
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting a) CAA. 0;4c Orr es
<br />In death)
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />• Sequentially list conditions,
<br />cause listed e ` C pira. {ar t. ,c 1 lU r'e. Da 7 S If
<br />any, leading to the cause listed b) /
<br />on Tine a. DUE TO, A OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE c) r , c1. T L c /n '4c c re nIa / /-/ ceno rrba 6-G DAL'S
<br />injury Initiated
<br />(disease or that
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST
<br />d) / - h 1 4 ' cmmbo /iG C U'cr0f/aSCt.(ar aCc, -, 0 al5
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ' NO
<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 k pregnant within the past year
<br />21a. MANNER OF DEATH
<br />Nature) ❑ Homicide
<br />Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES IX NO
<br />T`
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY A f WORK?
<br />OYES p0 NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF OF INJURY - STREET & NUMBER, APT. 540. CITYITOWN STATE ZIP CODE
<br />a W
<br />I u.
<br />I
<br />E ui
<br />8 40
<br />0 u U
<br />W a n d
<br />~
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />( 2 -- 1 7 -- 1/
<br />Z
<br />3'02
<br />] O
<br />.a. _I
<br />E x 0
<br />° W
<br />Z z
<br />, O =O
<br />~ 0 o
<br />24a. RATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />(2 2Q -
<br />23c. TIME OF DEATH
<br />/C 2D m
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />d ue t the caus es) s t a ted . (S lire an d Title)
<br />Lr.w-
<br />24e. On the basis of examination andlor investigation, in my opinion death occurred
<br />at the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE T HE 9EATH?
<br />❑ YES ❑ NO ❑ PROBABLY 2(J UNKNOWN
<br />H
<br />263. H 5 RGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable R 26a Is NO ❑ YES yJ N
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY)
<br />SC an L. c ascr) M.0. 555 5Dtf47 70'x'' Lrnco%
<br />(Type or Print) �\
<br />NE i 85(0
<br />P
<br />28a. REGISTRA NATURE X.44.4=4,44„,
<br />28b DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />DEC 23 20]#
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH : 411 "MYf iAt RVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR4S,404 R ERART M,l€AdT, EALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR V,ITA1,_ RECO
<br />DATE OF ISSUANCE
<br />DEC 302011
<br />LINCOLN, NEB
<br />STATE OF NEBRASKA
<br />201706960
<br />/r
<br />STANLEY S..0O3,fPER
<br />AS ISTAN T. tTE�,,#�,"E iSTRAR
<br />D AATi4ErOF"!4EALtM AND
<br />NEBRASKA HUMAN SEt$.t . , j t ?
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH I , '
<br />X
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