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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AN HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEB(, 4SKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />11/19/2013
<br />20190142►
<br />STANLEY S. COOPER
<br />ASSISTANT STATE 'REGISTRAR
<br />DEPARTMENT OF HEAL !•TH AND
<br />LINCOLN, NEBRASKA HUMAN. SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES"
<br />CERTIFICATE OF DEATH
<br />13 04900
<br />To be completed/verified by: FUNERAL DIRECTOR I
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Thomas James Huffman
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November 12, 2013
<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 />Newark, Ohio
<br />(Yrs)
<br />61
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />March 21, 1952
<br />7. SOCIAL SECURITY NUMBER
<br />101-44-1030
<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 />Saint Francis Medical Center
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 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
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1324 N. Greenwich Street
<br />90. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Linda L McCurdy
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />James Huffman
<br />12. MOTHER'S -NAME (First, Middle, Maiden Sumame)
<br />Alice Sands
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Linda Huffman
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Derek Apfel
<br />16b. LICENSE NO.
<br />1240
<br />16c. DATE (Mo., Day, Yr.)
<br />November 15, 2013
<br />o Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />To be completed by: CERTIFIER
<br />13. PART!. Enter the chain of events --di , injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />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 .. vacation resulting
<br />onset to death
<br />2 Weeks
<br />in death) DUE TO, OR AS A CONSEQUENCE OF: l onset to death
<br />Sequentially list conditions, if b) Pneumonia 1 2weeks
<br />any, leading to the cause listed I
<br />I
<br />line
<br />on a.
<br />DUE TO, OR AS A CONSEQUENCE OF: : onset to dee
<br />Enter the UNDERLYING CAUSE c) 1
<br />(disease or Injury that initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />LAST d) I
<br />1
<br />I
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Chronic Obstructive Lung Disease, Diastolic Heart Failure
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES ® NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ® NO
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />0 Suicide ❑Could not be determined
<br />0 Pedestrian
<br />o Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 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 & 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 />November 12, 2013
<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 />November 14, 2013
<br />23c. TIME OF DEATH
<br />02:01 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />23d. To the beat of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature end Title)
<br />David R. Colan, 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 />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR ISSUE r • ATION BEEN CONSIDERED?
<br />0 YES El NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />David R. Colan, MD, 729 North Custer Avenue,
<br />Grand Island, Nebraska, • 803
<br />r
<br />18a.2REGISTRAR'S SIGNATURE -
<br />-�0-{�
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />November 15, 2013
<br />
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