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11
<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, 20
<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 />6/25/2018
<br />LINCOLN, NEBRASKA
<br />RUSSELL FOSLER DEPARTMENT HEALTH AND
<br />INTERIM ASSISTANT STATE REGISTRAR HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />18 07820
<br />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.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />David Andrew Green
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />June 6, 2018
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Harrisburg, Pennsylvania
<br />(Yrs.)
<br />71 _
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />June 6, 1947
<br />7. SOCIAL SECURITY NUMBER
<br />553-68-3989
<br />8a. PLACE OF DEATH
<br />HOSPITAL © Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />❑fR/Outpatient 0 Decedent's Home
<br />❑ 004 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE COUNTY
<br />Nebraska 19b.
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />3810 Mary Lane
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10a MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married
<br />© Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />1013, NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />SUe Ellen Nelson
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Homer Green
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Anna Marie Bisser
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 01/01/1965-01/01/1968
<br />14a. INFORMANT -NAME
<br />Sue Ellen Green
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />June 7, 2018
<br />E Cremation 0 Entombment
<br />❑'Removal ❑ Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlawn Memorial Park Crematory Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Livingston -Sondermann Funeral Home, 601 N. Webb Road. Grand Island, Nebraska
<br />17b. Zip Code
<br />68803
<br />CAUSE OF DEATH (See instructions and examplesl
<br />18. PART t. Enter the chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter temunal events such as cardiac arrest, APPROXIMATE INTERVAL
<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 />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Respiratory Failure
<br />disease or condition resulting
<br />onset 80 death
<br />2 Days
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially fist conditions, it b) Gastrointestinal Bleeding
<br />any, leading to the cause listed
<br />linea.
<br />onset to death
<br />2 Days
<br />on
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) Esophageal Cancer
<br />(disease or injury that initiated
<br />onset to death
<br />6 Months
<br />the events resetting in deaths - DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES E NO
<br />20. IF FEMALE:
<br />0 Not pregnant withinpast year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />Accident Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ENO
<br />0
<br />0
<br />0
<br />Not pregnant, but pregnant within 42 days of death
<br />Not pregnant but pregnant 43 days to 1 year before death
<br />Unknown if pregnant within the past year
<br />0 0
<br />0 suicide Could be determined 0ouermine
<br />❑Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH'?
<br />0 YES 0 r NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home,
<br />farm, street, factory, office building,
<br />construction site, etc. (Specify)
<br />22d. INJURY AT WORK? ;
<br />❑YES ❑No
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be completed by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 6, 2018
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />June 7, 2018
<br />23c. TIME OF DEATH
<br />09:15 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.
<br />24d. TIME PRONOUNCED DEAD
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Douglas Herbek, MD
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES 0 NO E PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE
<br />0 YES
<br />DONATION BEEN CONSIDERED?
<br />7 NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES ©NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Douglas Herbek, MD, 2444 W. Faidley Avenue,
<br />Grand Island, Nebraska, •'803.
<br />28a. REGISTRAR'S
<br />SIGNATURE ii_ a„,,,...,,,
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 19, 2018
<br />
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