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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE 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,!{, CLORDS. DATE OF ISSUANCE 03/10/2015 201807930 STANLEY S COOPER ASSISTANT STATE REGISTITAI , DEPARTMEIII F..Of, HEALTH:4Na' LINCOLN, NEBRASKA HUMAN SERVICES `-" •. '''' STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIBi-ES CERTIFICATE OF DEATH 15 01286 To be completed/verified by: FUNERAL DIRECTCR ' 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Earl Lavern Shehein 2. SEX -' ' ' Male. - -'' 3: DAtiOF17EATH (Mo., Day, Yr.) > tAarO'2,`2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1-DA`7-"V8-'DATE OF BIRTH (Mo., Day, Yr.) Doniphan, Nebraska (Yrs.) 82 MOS. DAYS HOURS MINS.. April 2, 1932 7. SOCIAL SECURITY NUMBER 505-38-7189 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC 0 Hospice Facility 6b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis u ER/Outpatient 0 Decedent's Home ❑ DOA 0 Other(Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 525 Kennedy Drive 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Donna Carpenter 11. FATHER'S -NAME (First, Middle, Last, Suffix) David Earl Shehein 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Burl Mary Jackson 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 11/18/1952-11/02/1954 14a. INFORMANT -NAME Donna Shehein 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION IZI Burial ❑ Donation 16a. EMBALMER -SIGNATURE Chris McCoy 16b. LICENSE NO. 1191 16c. DATE (Mo., Day, Yr.) March 6, 2015 ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Doniphan Nebraska Cedarview Cemetery P 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 j CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 18. PART 1. 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) Cardiopulmonaey Arrest disease or condition resulting onset to death Immediate in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) Myocardial Infarction any, leading to the cause listed onset to death 10 Days on line a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury that initiated onset to death the events resulting in death( DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) 18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting ?r. the underlyiny cause given in PART 1. Obstructive Lung Disease,myasthenia Gravis, 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? 0 YES ® NO 20. IF FEMALE: ❑ Not pregnant within past year Pregnant at time of death❑Accident 21a. MANNER OF DEATH ® Natural ❑ Homicide 21b. IF TRANSPORTATION INJURY 0 Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ®NO 0 0 Not pregnant, but pregnant within 42 days of death❑ 0 Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown i/ pregnant within the past year 0 Pending Investigation 0 Suicide 0 Could not be determined Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 VES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 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 CERTIVIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) March 2, 2015 To be compleled by CORONER'S PHYSICIAN or COUNTY ATTORNEY Ort.Y 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) ' March 3, 2015 23c. TSnE OF DEATH 03:34 PM 21^,. PPONOUNCED DEAD !Mo.: Day, Vr.) 24d. TIME PRONOUNCED DEAD 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Ryan D. Crouch, DO :4e ^-n 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 Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES 0 NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES 0 NO 27. NAME, TITLE AND ADDRE S aF ERTIFIER (Type or Pnnt Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE Ail f 28b. DATE FILED BY REGISTRAR (Mo., Day, Vr.) March 5, 2015