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ArAtik 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 LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 2/22/2018 LINCOLN, NEBRASKA STATE OF NEBRASKA 20180150) 'Mr VI STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH r!, Lu re z u- .0 I 0. 0 0 0 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Anthony LaVel Birch 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Oma ha, Nebraska 7. SOCIAL SECURITY NUMBER 508 -90 -8349 813. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE-STATE Nebraska 13. EVER IN U.E ARMED .FORCES? Give dates of service if Yes. (Yes, No, or Link.) No Enter the UNDERLYING CAUSE tdicease or in jury that initiated ... ...... ...... a ...: the events resulting in deaths ) LAST 20. IF - FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death Not p regnant, but pregnant 43 days to 1 year before death Unk if pregnant within the past year ❑. 22a. DATE OF INJURY (Mo., Day, Yr.) 22d- INJURY AT WORK? ❑YES 0 N 25. DID TOSAOCO USECONTRIBUTE TO THE DEATH? YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 5a. AGE - Last Birthday (Yrs.) 54 9b. COUNTY Hall 10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married • ❑ Married, brit separated ❑ Widowed ❑ Divorced ❑ Unknown Last, Suffix) 11. FATHER'S -NAME (First, Middle, Sidney Dean Birch 15. METHOD OF DISPOSITION Q Burial ❑ donation ❑ Cremation ❑ Entombment ❑ Removal D ottier (Specify) 175. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Curran Funeral Chapel, 3005 S. Locust St.. Grand Island. Nebraska 22b. TIME OF INJURY 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 23a. DATE OF DEATH (Mo., Day, Yr.) February 11, 2018 a as Eti o ti E U Z 2 e e, 0 3d. To the best of my knowledge, death occurred at the time, date and place I and due to the cause(s) stated. (Signature and Title) ~ Steven Husen, MD 23b. DATE SIGNED (Mo., Day, Yr.) February 14, 2018 23c. TIME OF DEATH 01:26 PM 28a. REGISTRAR'S SIGNATURE /)].� /j _ bb. UNDER 1 YEAR MOS. 9d. STREET AND`NUMBER 830 N. North Rd. 16a. EMBALMER - SIGNATURE Patricia R. Curran DAYS 2. SEX Male Sc. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) February 11, 2018 March 1, 1963€ 6. DATE OF BIRTH (Mei., Day, Yr.) 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home/LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 5e. APT. NO. 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Theresa R Costello 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Doretha Dora Neal 14a. INFORMANT -NAME Theresa R Birch 6b. LICENSE NO. 1092 16d. CEMETERY, CREMATORY OR OTHER LOCATION Grand Island City Cemetery CITY / TOWN Grand Island STATE Nebraska CAUSE OF DEATH JSee instructions and examples) 18. PART I. Enter Me chain of events- -diseases, injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause bn a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Acute Pulmonary Embolus disease or condition resulting APPROXIMATE INTERV 30 Minutes in death) Sequentially list conditions, if any leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: b)Acute Thrombosis Of Superior Vena Cava And Subclavian Vein onset t o death 5 Days DUE TO, OR AS A CONSEQUENCE OF: c) Malignancy Related Hypercoaguable Syndrome onset to death 1 Month DUE TO, OR AS A CONSEQUENCE OF: d) Primary Lung Cancer, Right Uppe onsetto death 2 Months 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Superior Vena Cava Syndrome 27 } b � - , y IF TRANSPORTATION INJURY f--I Driver /Operator ❑ Passenger pedestrian Other (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE > s w E w z O z 80 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATtON BEEN CONSIDERED? ❑ YES i7 • 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (MO„ Day, Yr,) February 16, 2018 17b, Zip Code 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? .. ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES p NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and /or investiga ion, in my Opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO DYES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, ; 68803 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) February 20, 2018 i