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Pursuant to section 30 -2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Melvin LaRue Miner 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) July 14, 2018 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Fumas County, Nebraska 5a. AGE - Last Birthday (Yrs.) 91 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) April 15, 1927 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -26 -8134 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility 8b. FACILITY -NAME (if not Institution, give street and number) CHI Health St. Francis ❑ ER/Outpatient ❑ Decedent's Home 0 DOA ❑ Other(Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall Sa. RESIDENCE-STATE Nebraska 9b. COUNTY Hall '9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 4035 Edna Drive 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS 2 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 Beulah Belle Brown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Cecil Thompson Miner 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mary Etta Stitzel 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 09/13/1945- 10/19/1946 14a. INFORMANT.NAME Beulah Belle Miner 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑Entombment ❑ Removal ❑ Other ;(Specify) 16a. EMBALMER - SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) July 16, 2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH ee in tructi. n - nd exam • les 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 if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Myocardial Infarction disease or condition resulting onset to death 1 Day M death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) any, leading to the cause listed on line a - - - DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (disease or injury that initiated.. the events resulting in death) : -:: DUE TO, OR AS A CONSEQUENCE OF: onset to death • LAST d) 1 8. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Multi system Failure 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El No D. IF FEMALE: ❑ Not pregnant within past yew 0 Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant y p gnant 43 days to year before death ❑ unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation 0 Suicide nrined ❑ Ct ter 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other(Specdy) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES Q NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) July 14, 2018 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) July 16, 2018 23c. TIME OF DEATH 08:50 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Richard Fruehlinq, 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(s) stated. (Signature and Ttle) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES 2 NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Richard Fruehling, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S Stf,NATURE 28b. DATE FILED BY REGISTRAR (MO., Day, Yr.) July 17, 2018 „ttttttta i t l t tt eta lltttt STATE OF NEBRASKA , Te �p�z .N w.)"o 'stdd e 9�T 4 +ttS6Mt4NkMP • tatidNY. PPx ..xlrfl11tW4 it � : am/ '... -., .2fiv �� -. -. - .. , tttttttt 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 201806136 INTERIM A SI STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OP HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH DATE OF ISSUANCE 7/24/2018 LINCOLN, NEBRASKA