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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH (ND'HU)C1AN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA"DEPARTMENT, pF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL E'OR ZS =.
<br />DATE OF ISSUANCE
<br />MAY 162012
<br />LINCOLN, NEBRASKA
<br />201904170
<br />STAINLEYS. cQQPRR
<br />ASSISTANT ,At -L, R I TRAR
<br />DEPAff?JJENfOF HEALTH -Mb
<br />HUMAN-, ,ERVICES -
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE'23-314S
<br />Amended May 16, 2012 CERTIFICATE OF DEATH
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Henry
<br />Alfred -e4- Kincheloe
<br />2. SEX
<br />Male
<br />r^ Q. DAT7?Ot'DEATH (Mo-,Dey,YY:)
<br />April 20, 2012
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Lexington, Nebraska
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />87
<br />5b. UNDER 1 YEAR
<br />6c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />October 12, 1924
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />508-12-4661
<br />8a. PLACE OF DEATH
<br />HOSPITAL' ❑ Inpatient OTHER. 0 Nursing Home/LTC ❑ Hospice Facility
<br />0 ER/Outpatient - © Decedent's Home
<br />0 DOA ❑Other(Specify)
<br />8b. FACILITY -NAME (11 not l.stltullon, give street and number)
<br />2803 W. Forrest St.
<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 />2803 W. Forrest St.
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />E Yea 0 No
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Dorothy Ottman
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) -
<br />John Henry Kincheloe
<br />12. MOTHER'S -NAME (First, Middle, Maiden Sumame)
<br />Ida Colb
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or unit) Yes 05/17/1943-07/26/1945
<br />14a. INFORMANT -NAME
<br />Dorothy Kincheloe
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />®Burial ❑Donatione�
<br />❑Cremation ❑Entombment
<br />El Removal ❑Othedspeclry)
<br />16a. EMB L ER -SIGNATURE
<br />16b. LICENSE NO.
<br />Z7Z74///
<br />16c. DATE (Mo., Day, Yr.)
<br />April 25, 2012
<br />16d. CEMETERY, CREMAT Y OR OTHER LOCATION CITY/TOWN STATE
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17e. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />19. PART 1. Enter the 15.10 of events - diseases, injuries, or complications - l hat directly caused the death. DO NOT anter terminal events such as cardiac arrest,
<br />respirator/ arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final r-��
<br />disease or condition resulting a) \ \♦ r� ' Iv
<br />in death) 1 {�`" �S\
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />` • ` den
<br />vid
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, If b) A e
<br />any, leading to the cause listed 1 1A'C O �C\e. \1- 13 V
<br />onset to death
<br />t OSS
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />injury that Initiated
<br />onse to death
<br />(disease or
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />d)
<br />onset to death
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />--M-("C\��,i A.
<br />19 WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />20. IF FEMALE:
<br />❑Not pregnant within past year
<br />❑ Pregnant at time of death
<br />0 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 />21a. MANNER OF DEATH
<br />` ,1Vatural 0 Homicide
<br />❑`Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES L.
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES it NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK? 122e. DESCRIBE HOW INJURY (.CCURRED
<br />❑YES 1,;:o
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />�LL
<br />H-
<br />cv Crt�
<br />Ego
<br />NU
<br />o W
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />Apc.,\ ao sola
<br />z
<br />.0�Z
<br />d } 0
<br />m =
<br />-0- CI-
<br />' W Z
<br />0 O
<br />o
<br />~ U `o
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />APC11 3o. Ola
<br />23c. TIME OF DEATH
<br />l' PO AP
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and dug to the cause(s) stated. ( lure and Title)
<br />��'` , -.� u
<br />/ i1 � -16.77,4A-1% 1 - 3 0 -- i Z
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred
<br />at 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 ❑ NO ❑ PROBABLY UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ►! a
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES Ili NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, C - •PHYSICIAN OR COUNTY ATTORNEY)
<br />T'acs1rtck_ Ccontn ' \I ASV. Gaol N ••. - 6-0.fld Z.
<br />(Type or Priest),
<br />na Nobcck a L,Reb ,
<br />28a. REGISTRAR'S SIGNATURE
<br />AL
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />MAY 1 2012
<br />
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