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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTh 4'wY THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAkAEA pE tM@(413 HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FORYIT4t gECOj2QS... • lI CES, IT CERTIFIES HEALTH AND DATE OF ISSUANCE " 0 2 0 0 0 7 "1 L ' QQPER , 10/25/2012 k f�tLEY S. 8 AS tAN T TEAS D15P. b tlEAL ANQ� `< . LINCOLN, NEBRASKA HIIM4l1j'gSER ICE4 '' S ', STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SER ICES„, •. FAtTrr,„ - 1203897 CERTIFICATE OF DEATH I) 's', • +:.; To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Jerry M Miller 2. SEX t t` •,,`f Male • 31 DATE t9F DEATH (Mo., Day, Yr.) •:OCtober 10, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last Birthday 513. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Grand Island, Nebraska (Yrs.) 65 MOS. DAYS HOURS MINS. September 5, 1947 7. SOCIAL SECURITY NUMBER 505-56-5475 8a. PLACE OF DEATH mow& 0 Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility Si. FACILITY -NAME (If not Instibrtlon, give street and number) Saint Francis Medical Center ® ER/Outpatient 0 Decedent's Home 0 DOA 0 Other (Specify) Sc. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCESTATE Nebraska Sb. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 630 Eilenstine 9e. APT. NO. If. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Pamela Sober 11. FATHER'S -NAME (First, Middle, Last, Suffix) Francis F Miller 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mary K Cunningham 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Pamela Sober Miller 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ® Donation 16a. EMBALMER -SIGNATURE Paul Becker 16b. LICENSE NO. 1085 16c. DATE (Mo., Day, Yr.) October 11, 2012 ❑ Cremation 0 Entombment ❑ Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Nebraska Anatomical Board Omaha Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Nebraska Anatomical Board, 986395 Nebraska Medical Center, Omaha, Nebraska 17b. Zip Code 68198-6395 1 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 15. PART I. Enter the Oen of events -diseases, Injuries, or compticatlons4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without slowing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. IMMEDIATE CAUSE: MIMEDIATECAUSE (Final a) Acute Myocardial Infarction disease APPROXIMATE INTERVAL onset to death Immediate or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, If b) any, leading to the cause listed line onset to death on a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or Injury that Initiated onset to death Ste .vents resulting In death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: II Not pregnant within past year 0 Pregnant at tins of death 21a. MANNER OF DEATH ® Natural 0 Homicide o Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY 0 DrIwrtOperator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? 0 YES ®NO ❑ Not pregnant, but pregnant within 42 days of death El Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown it Pennant within tin pest year Suicide Could not be determined❑ ❑ ❑ Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE of DEATH? 0 YES 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? DYES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE E' W 23a. DATE OF DEATH (Mo., Day, Yr.) October 10, 2012 I 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH I 11 Y 23b. DATE SIGNED (Mo„ Day, Yr.) October 12, 2012 23c. TIME OF DEATH 11:20 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD s e a 23d. To the best of my knowledge, death occurred at the time, date and place and due b the caul** stated. (Signature and Title)E Richard Fruehling, MD 3 24e. On the baps of examination and/or Investigation, In my opinion death occurred at the time, dab and place and due to the cause(*) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ® YES 0 NO 0 PROBABLY 0 UNKNOWN ❑ YES 17 NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO 0 YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, raska, 68803 282. REGISTRAR'S SIGNATURE A. ! 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 19, 2012