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To be completed by: CERTIFIER I I To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENTS-NAME (First, Middle, Last, Suffix) George A Woolsey 2, SEX'I . ' •� Male ` 5. ATE O !bEATH (Mo., Day, Yr.) ., 'February "t2, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Oklahoma City, Oklahoma 5a. AGE - Last Birthday (Yrs.) 84 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.) January 21, 1931 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -28 -5234 8a. PLACE OF DEATH HOSPIT ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8b. FACILITY -NAME (If not Institution, give street and number) Good Samaritan Society -Grand Island Village 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 4075 Timberline Street re. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS I IM YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Mary Ann Murphy 11. FATHER'S -NAME (First, Middle, Last, Suffix) Bert W Woolsey 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Bernice Kerr 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 12/28/1950- 09/01/1954 14a. INFORMANT -NAME Julie Meier 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE James M. McLaughlin 16b. LICENSE NO. 951 16c. DATE (Mo., Day, Yr.) February 19, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Inland Cemetery Inland Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston - Butler - Volland Funeral Home, 1225 N. Elm, Hastings, Nebraska 17b. Zip Code 68901 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events -- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, ' APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines N necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Renal Failure disease or condition resulting onset to death 8 Weeks in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b) Card iomyopathy I Chronic any, leading to the cause listed I 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) I (disease or injury that initiated ; the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LAST d) I 1 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Dementia 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: ❑ Not pregnant within past year El 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 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pen Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? DYES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET 8. NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE k W 1 to r i c) z 23a. DATE OF DEATH (Mo., Day, Yr.) February 12, 2015 To be completed by CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) February 17, 2015 23c. TIME OF DEATH 10:22 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD g < O 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) S Ryan D. Crouch, DO 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) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN I 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES J NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803 1 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) February 20, 2015 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT -OF HEA4T'k! AND HUB AN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE'NEBR.4SS l ,p(= OF. HEALTH AND. HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSTI RY•FA 2, AI, RE.COP S,I r ` DATE OF ISSUANCE 02/24/2015 201801936 CERTIFICATE OF DEATH STANLEY S. COOPER r =l ASSIS ..W.72ATErREGIh DEP. AR? Tiat mr-At Ff yaN sJ./MAN SERVICES LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OFr HEALTH 'AND HUMAN,SE *';,, z, 15 01012