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STATE OF NEBRASKA 201807049 20170448
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ONFILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />AUG 0 8 2007
<br />LINCOLN, NEBRASKA
<br />60w
<br />TANLEYS. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />HEALTH AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPO8I
<br />CERTIFICATE OF DEATH n
<br />i. Utct UEN1'S-NAME (First, Middle, Last, Suffix)
<br />Carl R Amick
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 1, 2007
<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 />Arcadia, Nebraska
<br />(Yrs) 79
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />December 3, 1927
<br />7. SOCIAL SECURITY NUMBER
<br />508-28-9501
<br />6a. PLACE OF DEATH
<br />HOSPITAL: A Inpatient OTHER ❑Nursing
<br />Home/LTC ❑Hospice
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />K g:ti
<br />St. Francis Medical Center
<br />❑ ER/Outpatient 0 Decedent'sHome
<br />❑ IJQ4 0 Other
<br />Facility
<br />(Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />84 COUNTY OF DEATH
<br />Hall
<br />;..!, 9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Doniphan
<br />.,' 9d. STREET AND NUMBER 19e.
<br />410 Amick Avenue
<br />APT. NO 19f. ZIP CODE
<br />68832
<br />19g. INSIDE CITY LIMITS
<br />I 0 YES 01 NO
<br />MARITAL STATUS US AT TIME OF DEATH ,�c
<br />ai Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) H wife, give maiden name.
<br />Renee J. Youngs on
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Fred V. Amick Dr.
<br />12. MOTHER'S -NAME (First, Middle,
<br />Lillian R.
<br />Maiden Surname)
<br />Rydberg
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service 4 yes.
<br />(Yes, no, orunk.) Yes
<br />14a. INFORMANT -NAME
<br />Renee J. Amick
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />❑Burial ❑Donation
<br />16a. EMBALMER -SIGNATURE
<br />No Embalming
<br />16b. LICENSE N0.
<br />16c. DATE (Mo., Day, Yr. )
<br />August 1, 2007
<br />diCremation ❑Entombment
<br />r; ❑Removal ❑ Other (Specify)
<br />16d.CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />BV Cremation Center Hastings
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City or Town, State) 12-25 North Elm Avenue
<br />Livingston -Butler -Volland Funeral Home Hastings, Nebraska
<br />i 4 frh•: . ...x: T Y i 6 5 `. P :''. ' k`
<br />Y -.. ,� .... .... t .;,.;; t. , , ..,a.. •n sre.W*as'.a' z xx.�: ,G r.;''
<br />18 PART I. Enter the
<br />17b. Zip Code
<br />68901
<br />. t .. g ^T t.1
<br />t' :' ^"r .�• ue':; ase'?'.4
<br />chain of events --diseases Injuries or complications --that directly caused the death. Do NOT enter terminal events 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 />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final (a) � { j�' `(y{- 't ` e w \ tL, `(
<br />disease or condition resulting -
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />`I �J AS
<br />r` l
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />in death)
<br />Sequentially list conditions, if (b)
<br />53 any, leading to the cause listed
<br />onset to death
<br />1
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />rt onlinea
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury that initiated (c)
<br />the events resulting In death)
<br />onset to death
<br />LAST'DUE TO, OR AS A CONSEQUENCE OF:
<br />(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 I.
<br />$ta
<br />NS V
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />»,4 20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />0 Pregnant at time of death
<br />0 Not
<br />21a. MANNER OF DEATH
<br />XTJatural 0 Homicide
<br />0 Accident Pending Investigation
<br />21 b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES VireN0
<br />pregnant, but pregnant within 42 days of death
<br />`< L 0 Not pregnant,but pregnant 43 days to 1 year before death
<br />0 Unknown 4 pregnant within the past year
<br />0 Suicide 0 Could not be determined
<br />0 Pedestrian
<br />❑Other (Specify)
<br />214. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (fvfo.jI
<br />tr
<br />�n# ,A`
<br />Day, Yr.)
<br />UV
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction
<br />site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />a -a
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />a 22f. LOCATION
<br />OF INJURY - STREET & NUMBER, APT NO. CITY/TOWN STATE 21P CODE
<br />TZ
<br />ri as
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<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 1, 2007
<br />a�W
<br />2
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
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<br />>.
<br />°1=}
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<br />23b. DATE SIGNED(Mo., Da Yr.
<br />Y. )
<br />�- 1- C.) -1
<br />23c.TIME OF DEATH
<br />5:20 a m
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<br />EaaZ
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<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24tl. TIME PRONOUNCED DEAD
<br />, s
<br />_
<br />23d. best orf�_r owled. -
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<br />., Fo Q
<br />aottthee .ccurr=- : e tim , date and place
<br />11,
<br />--WOW' re and�ijle ♦
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<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 CONTRIBUTETOTHE DEATH?
<br />0 YES 0 NO 0 PROBABLY VUNKNOWN
<br />27. NAME, TITLE
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ltk NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑YES NO
<br />AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Steven L. Husen M.D., 2116 W. Faidley Ave. Suite 400, Grand Island, NE 6880
<br />28a. REGISTRAR'S SIGNATURE
<br />�•
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />AUG 7 2007
<br />
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