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STATE OF NEBRASKA
<br />Amended
<br />WHEN THIS 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 LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />5/31/2018
<br />LINCOLN, NEBRASKA
<br />Amended
<br />5131/2018
<br />trreet Address
<br />201804012
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />j
<br />STANLEY COOPER
<br />ASSISTA STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Billy D Crapson
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Wauneta, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506 -46 -5621
<br />$b. FACILITY NAME (If not Institution, give street and number)
<br />CHI Health St, Francis
<br />8c. CITY OR TOWN OF DEATH (include Zip Corse)
<br />Grand Island 68803
<br />9a, RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />1513 l lth Avenue
<br />10a.. MARITAL STATUS. AT TIME OF DEATH ® Married ❑ Never Married:.
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FA THER'S -NAME (First, Middle, Last, Suffix)
<br />Rov Leo Crapson
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Removal ❑I Other (Specify)
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />in death)
<br />5equentiaFly list conditions, if ' b)
<br />any,; leading to the cause 1lsted
<br />on Fine a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury. that initiated
<br />the events resulting in death)
<br />LAST
<br />20. W FEMALE:
<br />❑
<br />Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 clays of death
<br />© 'Not pregnant, but pregnant 43 days to 1 year before death
<br />Unk if pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK ?.
<br />❑YES 0 N
<br />22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO.
<br />23a, DATE OP DEATH (Mo., Day, Yr.)
<br />Mav 2 201::8
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />May 14 2018
<br />Steven Husen, MD
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES El NO ❑ PROBABLY ❑ UNKNOWN
<br />Sa. AGE - Last Birthday
<br />(Yrs -)
<br />78
<br />9b. COUNTY
<br />Buffalo
<br />MOS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL © Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />16a. EMBALMER- SIGNATURE
<br />Matthew T. Myers
<br />17a. FUNERAL. HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />O'Brien- Straatmann- Redinoer Funeral Home. 4115 Avenue N. PO Box 2344, Kearney. Nebraska
<br />IMMEDIATE CAUSE:
<br />a) End Stage Pulmonary Fibrosis
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />22b. TIME OF INJURY
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the causeisj stated. (Signature and Title;
<br />CAUSE OF DEATH (See instructions and examples)
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />23c. TIME OF DEATH
<br />01:23 AM
<br />CITY/TOWN
<br />28a. REGISTRAR'S SfGNATURE
<br />Sb: UNDER 1 YEAR
<br />DAYS
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Kearney
<br />9e. APT. NO.
<br />MINS.
<br />10b.. NAME. OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Alta Schwasinger
<br />f 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Edith Wilma French
<br />14a. INFORMANT -NAME
<br />Alta Crapson
<br />16b. LICENSE NO.
<br />1411
<br />_..
<br />3. PART7, Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminalsevents such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />21b. IF TRANSPORTATION
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other(Specify)
<br />INJURY
<br />OTHER ❑ Nursing Home /LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />9f. ZIP CODE
<br />68845
<br />3. DATE OF DEATH(Mo., Day, Yr.)
<br />May 2, 2018
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />January 12, 1940 <:
<br />Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo„ Day, Yr,)
<br />May 8, 2018
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Riverside Cemetery Wauneta
<br />STATE
<br />Nebraska
<br />17b, Zip Code
<br />68847
<br />APPROXIMATE INTERVAL
<br />Unknown
<br />onset to death
<br />onset to death
<br />onsettO death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES 55 NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />STATE ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONO(
<br />EAD
<br />24e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />the dime, date ann place and due to the cause(s) stated. ( Signature and Title)
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand I
<br />land, Nebraska, 68803
<br />28b. DATE FILED BY REGISTRAR (Mn.:, Day, Yt)
<br />May 15, 2018
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