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STATE OF NEBRASKA
<br />W1f- EN, THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />• tit BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR4Si4'9&P.4$TM� ENT OFHEALTH AND
<br />F` )7
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY f-41 ifg1RIIS>i
<br />DATE OF ISSUANCE
<br />06/06/2012
<br />LINCOLN, NEBRASKA
<br />202000392,
<br />201302269
<br />v s.
<br />STANLEY S COQ,{?es;i., .
<br />•ASSISTANT S' ATE R'i,ISTRAR
<br />`,'DEPAkfiMENT' � f1-f'AND
<br />I- UMAN §ERv/PEVSJ t r'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUM/41 SE`RVJC¢E)
<br />CERTIFICATE OF DEATH '
<br />12 01981
<br />To be completedherified by: FUNERAL DIRECTOR I
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Linda Gail Green
<br />2. Sp') 7 , ' ' • • • ,
<br />Eernale_11- `_ ` �`
<br />1; DATE OF DEATH (Mo., Day, Yr.)
<br />2 .June 3, 2012
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Bkthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY_
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />St. Paul, Nebraska
<br />(Yrs.)
<br />65
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />January 11, 1947
<br />7. SOCIAL SECURITY NUMBER
<br />505-56-5202
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatlent =in ® Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (H not Institution, glve street and number)
<br />St. Francis Memorial Health Center LTC
<br />0 ER/Outpatlent 0 Decedent's Homs
<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 />4220 Nordic Road
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<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) H wife, gNe maiden name
<br />Floyd M Green
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Harold Joseph
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Made A White
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Floyd M Green
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCoy
<br />18b. LICENSE NO.
<br />1191
<br />16c. DATE (Mo., Day, Yr.)
<br />June 7, 2012
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Rose Hill Cemetery Palmer Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />1
<br />CAUSE OF DEATH (See instructions and examples)
<br />To be completed by: CERTIFIER
<br />16. PART I. Enter the Mut of events diseases, Injuries, or complicaaons4hat 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 ono cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Glioblastoma Multiforme
<br />disease or condition rssuNkrg
<br />- APPROXIMATE INTERVAL
<br />onset to death
<br />6 Months
<br />in dem) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading to the cause listed
<br />line
<br />onset to death
<br />on a. DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />(disease or Injury that Initiated
<br />onset to death
<br />the events resulting in death) 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 I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20. IF FEMALE:
<br />® Not pregnant within past year
<br />El Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 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 />❑ 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 />❑suicide ❑Could not be determined
<br />0 Pedestrian
<br />0 Other (SWAM
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />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 horses, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />mpMMd by
<br />CERTIFIER
<br />NLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 3, 2012
<br />B
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />June 4, 2012
<br />23c. TIME OF DEATH
<br />09:05 PM
<br />1 &).
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />. To the best of my knowledge, death ocarmd at the time, date and place and due to the causeis) stated. ISIgnatme and Title)
<br />due to site eauae(sl *teed. ($tgnsture and TNN)
<br />Kenneth Vetted, MD
<br />!ligZoe.
<br />~ g a
<br />the
<br />On h bads oT examination anderIinvestigationoccurredaton, In rely opinion death ourredand
<br />time, date and place and due to the cause(*) stated. (Signature and TNN)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE
<br />❑ YES
<br />DONATION BEEN CONSIDERED?
<br />® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable H 26a Is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY A'TORNEY)
<br />Kenneth Vettel, MD, 2116 W Faidiey #400, Box 9802, Grand Island, Nebraska, 68803
<br />(Type or Print)
<br />28a. REGISTRAR'S SIGNATURE- /� 128b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />(� June 5, 2012
<br />
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