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WHEN !! T 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 LE P t TC f YjF RECORDS
<br />ii �� STANLEY . / C •/ OOPER
<br />ASSISTA STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DATE OF ISSUANCE
<br />2/12/2018
<br />LINCOLN, NEBRASKA
<br />201801150
<br />1. DECEDENTS-NAME (First, Middle, Last, Suffix)
<br />Willie Rogers Brown
<br />4. CITY! AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Imo()
<br />ene, Iowa
<br />7. SOCIAL SECURITY NUMBER
<br />479 -50 -8616
<br />Bb. FACILITY -NAME (If not Institution, give street and number)
<br />tL'=
<br />Q
<br />Veterans Affairs Medical Center
<br />• 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />o Grand Island 68803
<br />9:J
<br />9a. RESIDENCE -STATE
<br />• Nebraska
<br />• 9d. STREET AND NUMBER
<br />LL
<br />n 123 West 12th St.
<br />v
<br />sm
<br />d
<br />• 11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />v I John Brown
<br />Da. MARITAL STATUS AT TIME OF DEATH IXI Married ❑ Never Married
<br />❑ Married, tuft separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />a
<br />0
<br />3. EVER IN U.S. ARMED.FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 08/03/1965- 08/02/1967
<br />2 15. METHOD OF DISPOSITION
<br />❑ Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Removal ;❑ Other (Specify)
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Metastatic Small Cell Carcinoma Of The Lung
<br />disease or condition resulting
<br />in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentiallylistconditions, if b)
<br />y . .. gt ._. e . (Wed
<br />on line a. .
<br />Enter the UNDERLYING CAUSE
<br />•(disease or injury, that initiated
<br />the d ents'resulttng in death)
<br />Coed Chf, DM Type, 2
<br />IY
<br />W
<br />µ, 20.IF SEMALE:
<br />❑ Not pregnant within past year
<br />U ❑ Pregnant at time of death
<br />E
<br />0
<br />.0
<br />0
<br />❑ Not pregnant, pregnant within 42 days Of death
<br />0 0, Not pregnant :but pregnant43 days to 1 year before death
<br />(Jnke iWn If pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />!2d. INJURY AT WORK?
<br />❑YES ❑ NO
<br />23 a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 4 2018
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />February 6, 2018
<br />9b. COUNTY
<br />Hall
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />3d. 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 />Shawn S. f-awrence, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />rA YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES El NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Shawn S. Lawrence, MD, 223 South E St, Broken Bow, Nebraska, 68822
<br />28a, REGISTRAR'S SIGNATURE /lam J6 _ / "-
<br />23c. TIME OF DEATH
<br />10:53 AM
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />73
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL © Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />HOURS
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MINS.
<br />OTHER ❑ Nursing Home /LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />9f. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Penny Caroline Fife
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Oma Ross
<br />14a. INFORMANT -NAME
<br />Penny Caroline Brown
<br />16a. EMBALMER - SIGNATURE
<br />Stacie L. Ruiz
<br />16b. LICENSE NO.
<br />1495
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street. Grand Island. Nebraska
<br />s. PARTL Enter that <chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory attest, or ventricular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause On a line. Add additional lines if necessary.
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />21a. MANNER OF DEATH
<br />® Natural ❑ 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 />24a, DATE SIGNED (Mo., Day, Yr.)
<br />26a. HAS ORGAN OR TISSUE, DONATION BE CONSIDERED?
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />February 4, 2018
<br />6. DATE OF BIRTH (MO., D
<br />November 17,.
<br />9g! I NSIDE art LIMITS
<br />® YES ❑ NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16c. DATE (Mo., Day, Yr.)
<br />February 9, 2018
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Cemetery
<br />CITY / TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17b, Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />APP INTERVAL
<br />One Year
<br />onset to death
<br />onsettodeath
<br />24b. TIME OF DEATH
<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 />❑ Hospice Facility
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES 4a3 NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES El NO
<br />21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑' NO
<br />22b. TIME OF INJURY
<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 />ZIP CODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 6, 2018
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO DYES ❑ NO
<br />
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