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I To Be Completed/Verified by: FUNERAL DIRECTOR �— J
<br />1. DECEDENTS - NAME (First, Middle, :.: Last, - . Suffix)
<br />Alvin Martin Glover
<br />2. SEX `. - --
<br />Male
<br />' DATE OF -DEATH (Ms,Dsy,Yr)
<br />February 22, 2014
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Wood River, Nebraska
<br />Ha. AGE -Last Birthday
<br />(Yrs.)
<br />83
<br />6b. UNDER 1 YEAR
<br />6c. UNDER 1 DAY
<br />S. DATE OF BIRTH (Mo.,. Day, Yr.)
<br />July 15, 1930
<br />MOB.
<br />DAYS
<br />HOURS
<br />MINE.
<br />7. SOCIAL SECURITY NUMBER
<br />507-32-5661
<br />Ss. PLACE OF DEATH
<br />HOSPITAL: 17 inpatient
<br />❑ :EWOutpatlent
<br />0 "o
<br />OTHEL Nursing HomeiLTC ❑ Hospice Facility
<br />Ob. FACILITY -NAME (If not Institudon, give street and number)
<br />Veterans Affairs Medical Center
<br />' ❑ Decedent's Home
<br />DOthMSVeaffy)
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Island 68803
<br />lid- COUNTY OF DEATH
<br />Hall
<br />Si. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9C. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER :
<br />2123 West 11th Street
<br />Se. APT. NO.
<br />Ill. ZIP CODE 3.
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />®Y.• ❑ No
<br />10a.: MARITAL STATUS AT TIME OF DEATH I I Married ❑ Never Married
<br />❑ but separated ❑ Widowed DlvercM ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle. Last, .. Suffix) N wife, give maiden name.
<br />Gloria Leigh Martin
<br />11. FATHER'S -NAME (First, Middle. Last, Suffix)
<br />Raymond Glover
<br />12. MOTHERS -NAME .(First, . Middle. Maiden Surname)
<br />Mildred Beagle
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unik) Yes 04/11/1953-11/17/1960
<br />14a. INFORMANT -NAME
<br />Larry Dean Glover
<br />lab. RELATIONSHIP TO DECEDENT
<br />Son
<br />16. METHOD OF DISPOSIT oN :
<br />Dhotis ❑DOnetlon
<br />El , ❑Pent
<br />Damnation ❑easroet ❑ way
<br />162. EMBALMER-SIGNATURE _ t
<br />13b. LICENSE NO.
<br />} � J
<br />ISO. DATE (MO., Day, Yr.)
<br />February 25, 2014
<br />�
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITYITOWN STATE
<br />Central City Cemetery Central City, Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Stab)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />lib. Zip Cods
<br />68801
<br />M31U112133 : peselduloD e8
<br />CAUSE OF DEATH (See instructions and examples)
<br />1a. PMT I. Enter dee I& .dI..ee.e, *05., or uepeatlone- that dnetly eased lie death, DO NOT sew busing events such as casdbc anat. :.
<br />nespbeary meet, r ventricular fibdaetlan without showing the gr etiology. DO NOT. ABBREVIATE En only one mud on• Rm. Add edditlann Ones a neoemry.
<br />IMMEDIATE CAUSE: ' :.
<br />IMMEDIATE CAUSE (Final 1
<br />disease or condition resulting a) �9 (�, /� \ C` ,
<br />in death)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />DUE TO, OR AS AtoNSEQUENCE OF � onset to death
<br />Sequentially list conditions, if
<br />any, leading to the cause dated b ) `.0 �\ >, ' 1 _ , • VI. Tr
<br />on gm a. DUE TO, OR AS A CONSEQUENCE OF: ^ l
<br />E UNDERLYING CAUSE c) C XQ f� El.l \ c i t l
<br />(ae or Injury that initiated
<br />(� onset to death
<br />\ �C'(16\,c c , `te UC1t� • y!
<br />U
<br />the events melded in death) DUE TO, OR A CONSEQUENCE OF N onset to death
<br />LAST
<br />d ) C hcvy (") a v e x.� mnac�c4 v.�eR.�e
<br />10. PART Ii. OTHER SIGNIFICANT CONDmONS•Cond tlona contdbutlrq to the death but not resulting In the undo /Ing cause given in PART L :
<br />C.C\COnt�t \tc V ` v5F4.`.R
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />El YES 141( NO
<br />20. IF FEMALE: '.
<br />❑ Not pregnant within past year
<br />❑ Pregnant at lime of death
<br />❑Not pregnant, but pregnant witk t 42 days of death
<br />❑Not pregnant, but pregnant 43 days to 1 year before death
<br />❑Unknown N pregnant within the past year
<br />21a. MANNER OF DEATH
<br />Natura ❑ Homicide
<br />El Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />\
<br />21d. WERE M AUSE FINDINGS AVAILABLE
<br />TO COMPLETE SE OF DEATH?
<br />❑YES so
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction sits. etc. (Specify)
<br />22d. INJURY AT WORK?
<br />ID yes 0 N
<br />22.. DESCRIBE HOW INJURY OCCURRED
<br />221 LOCATION OF . INJURY - STREETS NUMBER APT. NO. CITY/TOWN STATE ZIP CODE
<br />AAN0
<br />11314LLN307/01U311
<br />e9 o1
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />thT lA Qcl Ica c.0 Li
<br />Z
<br />1 .?,
<br />24a. DATE SIGNED (Me., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED ma,. Day, Yr.) '
<br />kercktOrS\ aa J a014
<br />23C. TIME OF DEATH
<br />:4d cum
<br />1 O
<br />�<
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />23d. To the best of occurred at tie time, date and place 1 E
<br />. :) • to th 1 cause( ®,,y � ,^ l (SignF. and Title)) -
<br />■ / .Iii /�1 - � 17 rg
<br />24e. On the bads of examination and/or investigation, In my opinion death occurred
<br />the time, date and place and due to t cause(e) stated. (Sgnature and Me)
<br />25. DID TOBACCO USE C' r • TO THE ,
<br />�Ll 01 ES ❑ . NO ❑ PROBABLY :❑ UNKNOWN
<br />•- 27.
<br />28.. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />ID
<br />❑ Y ` NO
<br />21b. WAS CONSENT GRANTED?
<br />Not Applicable If Sea Is NO YES ❑ NO
<br />HAIM, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />- T e t ( L) e W i C t TINn YArTr c ` a6 i N e rn(xi w e t l fzca s)d „ T+,s1
<br />Ad N uba n Is &
<br />P
<br />211a SIGNATURE
<br />Ataii d (
<br />ma. DATE FILED BY REGISTRAR (Mo., Day. Yr.)
<br />MAR 3 20M
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NNBRAS 4* AY .TINICl T OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR 1GTTf ,„030
<br />DATE OF ISSUANCE
<br />03/05/2014 20180263 ass LATER
<br />DEBARTM Ti
<br />LINCOLN, NEBRASKA HUMAN S RVICEs
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES*,
<br />CERTIFIGATE.AF 1]EATI4
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