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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) George Dingwall AIIan Jr 2. SEX - ^ Male '..Y ` . 3. DATE OF DEATH (Mo., Day, Yr.) May 31, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Wood River, Nebraska 5a. AGE - Last Birthday (Yrs.) 88 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) July 22, 1926 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -28 -1541 8b. FACILITY -NAME (If not Institution, give street and number) 17596 West Wood River Road 8a. PLACE OF DEATH )1OSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient I Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Wood River 68883 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Wood River 9d. STREET AND NUMBER 17596 West Wood River Road e. APT. NO. 9f. ZIP CODE 68883 9g. INSIDE CITY LIMITS ❑ 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 Dolores J Greenwood 11. FATHER'S -NAME (First, Middle, Last, Suffix) Geroge Dingwall Allan Sr 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ina Benton 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Dolores J Allan 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Chris McCoy 16b. LICENSE NO. 1191 16c. DATE (Mo., Day, Yr.) June 4, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Cameron Cemetery Wood River Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 L CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 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 onset to death 6 Months respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines H necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Chronic Respiratory Failure disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b) Chronic Obstructive Pulmonary Disease i 20 Years any, leading to the cause listed I 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: i 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: 1 onset to death LAST d) 1 1 1 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Chronic Cerebralvascular Disease,server Vascular Dementia,chronic Atial Fibulation,Sinoatrial Node Dysfunction 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 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 21a. MANNER OF DEATH ID Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 'XI 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? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 123a. DATE OF DEATH (Mo., Day, Yr.) Z W I May 31, 2015 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH F 23b. DATE SIGNED (Mo., Day, Yr.) E ' z June 3, 2015 23c. TIME OF DEATH 02:27 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3 u O 23d. To the best of my knowledge, death occurred at the time, date and place c and due to the cause(*) stated. (Signature and Title) t2 Steven Husen, MD 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(a) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OFtERTIFIER (Type or Print Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 1 28a. REGISTRAR'S SIGNATURE - lR� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) June 3, 2015 Amended STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA3EP,ARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FQtt VITA4 RE,C hio4. Amended 07/02/2015 Item 25 corrected DATE OF ISSUANCE 07/02/2015 LINCOLN, NEBRASKA 201802477 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN,SERWCES CERTIFICATE OF DEATH n --STANLEY S. COOPER, ASSISTANT STATE REGISTRAR DEPA$TMEN, O HEALTH A' VD 'SERVS c'; 15 03230