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<br />STATE OF NEBRASKA � f�allt. sit
<br />WHEN '! THIS "COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />4/11/2017
<br />LINCOLN, ■EBRASKA
<br />201'708347
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH! AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />1. DECEDENTS -NAME (First, Middle, Last, ' Suffix)
<br />Charles Stephen Chapman
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Fremont, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508 -36 -4424
<br />8b. FACILITY -NAME (Knot Institution, give street and number)
<br />CHI Health St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE- STATE
<br />Nebraska
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk,) Yes 02/07/1956-02/06/1962
<br />15. METHOD OF .DISPOSITION
<br />® Burial ❑ Donation
<br />® Cremation ❑ Entombment
<br />❑ Removal 0 Other (Specify)
<br />20. IF FEMALE:'
<br />❑ Not pregnantwithin past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnam;:bot pregnant within 42 days of death
<br />© Not pregnant, but pregnant:43 days to 1 year before death
<br />❑ Unknown irpregnantwithiirthe past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES ❑ NO
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN
<br />28a,1 EGISTRAR S SfG
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />81
<br />9b. COUNTY
<br />Hall
<br />9d. STREET AND NUMBER
<br />2705 O'Flannagan St
<br />10a. MARITAL STATUS ATTIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, butseparateci, ❑ Widowed ❑ Divorced ❑ Unknown
<br />16a. EMBALMER - SIGNATURE
<br />Not Embalmed
<br />22b. TIME OF INJURY
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide [3 Could not be determined
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />March 31, 2017
<br />23c. TIME OF DEATH
<br />04:12 PM
<br />a. DATE OF DEATH (Mo., bay, Yr.)
<br />March 30, 2017
<br />d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Kenneth Vette1, MD
<br />NATURE 3- / o ff -`
<br />5b. U
<br />NDER 1 YEAR
<br />MO
<br />DAYS
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />9e, APT. NO.
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 1511 NO
<br />MINS.
<br />9f. ZIP CODE
<br />68803
<br />14a. INFORMANT -NAME
<br />Mary Kay Chapman
<br />16b. LICENSE NO.
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)!'
<br />Curran Funeral Chapel. 3005 S. Locust St.. Grand Island. Nebraska
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />21b,1FTRANSPORTATION INJURY
<br />0 Driver /Operator
<br />0 Passenger
<br />Pedestrian
<br />0 Other (Specify)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />March 30, 2017
<br />6. DATE OF BIRTH (Mo., Day, Yr.),
<br />August 19, 193
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER ❑ Nursing Home /LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />❑ Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand ,Island'
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Mary Kav Fogarty
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) L 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Jack Chapman
<br />Edith Button
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />March 31, 2017
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />STATE
<br />Nebraska
<br />17b. Zip Code z.
<br />68801
<br />in death)
<br />Sequentially list cendition$, if `£
<br />any, Leading to the cause listed:
<br />on line a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Sepsis
<br />CAUSE OF DEATH (See instructions and examples)
<br />1tt. PART I. Einar the chain of events- -diseases, Injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrett, orventrieofar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cease an a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Non ST Elevated Myocardial Infarction
<br />disease or condition resulting
<br />APPROXIMATEINTERVAL:.
<br />onset to death
<br />Days
<br />onset to death
<br />Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) Cerebral Vascular Accident
<br />tdiseaseot injury that initiated
<br />onset to death
<br />events Easuhi
<br />LAST:
<br />Ig
<br />death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES 511 NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH$;
<br />❑ YES ❑ No
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />CITY /TOWN
<br />STATE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investiga ion, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Kenneth Vettel, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 5, 2017
<br />
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