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<br />WHEN ` THIS COPY CARRIES THE RAISED ` SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />7/5/2017
<br />LINCOLN: NESR4SKA
<br />202001404
<br />4 ate
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH' AND (HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />pleted/verified by: Fl1NERA'
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Helen Natalie Brittin
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />June 22, 2017
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE Last Birthday
<br />(Yrs.)
<br />91
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />May 12, 1926
<br />7. SOCIAL SECURITY NUMBER
<br />506-20-533.0
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />8a. PLACE OF DEATH
<br />HOSPITAL © Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />0 Hospice Facility
<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 />9d. STREET AND NUMBER
<br />1406 Sheridan Place
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />❑ Married, but separated' ® Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Jake Semm
<br />lob. NAME OF SPOUSE, (First,,
<br />Glenn Robert Brittin
<br />Middle, Last, Suffix) if wife, give maiden name
<br />12. MOTHER'S -NAME (First,
<br />Agnes Haney
<br />Middle, Maiden Surname)
<br />13. EVER IN U.S=ARMEDD.FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Don Robert Brittin
<br />14b. RELATIONSHIP TO DECEDENT:
<br />Son
<br />15. METHOD OF DISPOSITION
<br />❑ Burial -❑ Donation
<br />® Cremation 0 Entombment
<br />❑:Removal .. 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />June 26, 2017
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />ADfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />CITY / TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17b. Zip' Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />.. ..
<br />74. PARTE Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. 00 NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, ar vantnlular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one rause: On a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Intraperitoneal Carcinomatosis Metastatic
<br />disease or condition resuking
<br />in death)
<br />Sequentially fiat tond'Itiona, N
<br />any, leading to the cause octad
<br />on lint a.
<br />Enter the UNDERLYING CAUSE
<br />.(diseaee ar injuryinitiated:.:
<br />dg in death)
<br />1111, euanta (ssuei
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />APPROXIMATE INTERVAL'
<br />onset to death
<br />Months
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />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 1.
<br />Hypertension,. Martens Syndrome
<br />20. W FEMALE:
<br />0 Not pregnant NHth,n.pastyear
<br />0 Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 blot pregnant, but pregnsm 43 days to 1 year before death
<br />❑ thlknOWn ifpregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Diver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?,.
<br />❑YES 0 N
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />OYES ONO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 22, 2017
<br />234. DATE SIGNED (Mo., Day, Yr.)
<br />Jurie 22, 2017
<br />23c. TIME OF DEATH
<br />07:23 AM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Ryan D. Crouch, DO
<br />25. DID TOBACCO
<br />❑ YES
<br />USE CONTRIBUTE TO THE DEATH?
<br />NO 9 PROBABLY 0 UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investiga ion, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and TNM)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 7NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska,
<br />28a, REGISTRA*S SGNATURE 45
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (Mo Day, Yr.)
<br />June 28, 2017
<br />
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