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di STATE OF NEBRASKA • 7. SOCIAL SECURITY NUMBER 47.9 -50 -8616 �8b. FACILITY -NAME of not Institution, give street and number) 4r O Vet Affairs Medical Center a. <s1 W U I WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT 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 LEAoDfP,jj T ?iF4R6ITAL RECORDS DATE OF ISSUANCE 2/12/2018 LINCOLN, NEBRASKA 1. DECEDENTS- NAME (First, Middle, Last, Willie Rogers Brown 4. CITY: AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Imocene, Iowa Ui 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE- STATE Nebraska 9d. STREET AND NUMBER 123 West 12th St. 10a. MARITAL STATUS AT TIME OF DEATH El Married ❑ Never Married © Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) John Brown 3. EVER. IN U.S. ARMED FORCES? Give dates of service if Yes. Yes, No, or Unk.) Yes 08/03/1965- 08/02/1967 15. METHOD OF DISPOSITION 16a. EMBALMER- SIGNATURE 51:1 Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal , ❑ Other (Specify) Westlawn Cemetery 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if r' b) arty, leading to the:: cause Fisted On late a. Enter the. UNDERLYING CAUSE (diseaseer injury that initialed the events. rasultkfa n death) LAST 22a. DATE OF INJURY (Mo., Day, Yr.) o E 'd 0 22d ATIMOR#f? ❑ YES ❑ M0 . I 28e, REGISTRAR'S SIGNATURE Ix STANLEY COOPER 201801150 DEPARTMENT HEALTH AND AR HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 'CERTIFICATE OF DEATH Suffix) 9b. COUNTY Hall Stacie L. Ruiz DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 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 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 23a. DATE OF DEATH (Mo., Day, Yr.) February 4, 2018 23b. DATE SIGNED (Mo., Day, Yr.) 1 23c. TIME OF DEATH February 6, 2018 10:53 AM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Shawn S. Lawrence, MD 5a. AG Last Birthd (Yrs.) 73 y 14a. INFORMANT -NAME Penny Caroline Brown 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA lob. NAME OF SPOUSE (First,.. Middle, Last, Suffix) If wife, give maiden name Penny Caroline Fife CITY/TOWN b.- UNDER 1 YEAR MOS. 9c. CITY OR TOWN Grand Island 12. MOTHER'S - NAME (First, Middle, Maiden Surname) Oma Ross DAYS 9e. APT. NO. 2. SEX Male 8d. COUNTY OF DEATH Hall lab. LICENSE NO. 1495 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN CAUSE OF DEATH (See instructions and examples) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Shawn S. Lawrence, MD, 223 South E St, Broken Bow, Nebraska, 68822 5c. UNDER 1 DAY HOURS OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) Grand Island MINS. 9f. ZIP CODE 68801 lb. PART I, Enter the' chain of vents. -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or vet 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) Metastatic Small Cell Carcinoma Of The Lung disease or condition resulting in death) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Copd, Chf, DM Type 2 21b.IFTRANSPORTATION INJURY Driver/Operator ❑ Passenger Pedestrian El Other (Specify) STATE 24a DATE SIGNED (Mo., Day, Yr.) 3, DATE OF DEATH (Mo., Day, Yr.) February 4, 2018 6. DATE OF BIRTH (MO., D November 17, 1944; ❑ Hospice Facility 9g..INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr.) February 9, 2018 STATE Nebraska 17b, Zip Code 68801 APPROXIMATE INTERVAL onset to death One Year onset to lcea onset to death 21c. WAS AN AUTOPSY PERFORMED? ❑ YES NO 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 5i3 NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑' NO 24b. TIME OF DEATH 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) ZIP CODE 24c, PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) February 6, 2018 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO I YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)