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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTHAATbWb S�2 S, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA REPAMM 'MMMT; iii 11fEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR .WT (L RECQRDS: • •
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<br />DATE bF ISSUANCE
<br />SEP 0 9 2009
<br />LINCOUN, NEBRASKA__
<br />202003981
<br />u r
<br />StA!1LEY S.;-QQOPER
<br />AS'SISTANT,'ST.ATEiRE,GISTRAR~' r;
<br />DEPARTMENT OF HEALTH ,ANQ-:; .
<br />Hllly1At SERVICES ^ r
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<br />....
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPOTI8 2?21
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Richard Lee Milton
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 19, 2009
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Omaha, Nebraska
<br />5a. AGE -Last Birthday
<br />(Yrs.) 63
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />January 3, 1946
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />505-60-1261
<br />13e. PLACE OF DEATH
<br />HOSP119L: Di Inpatient Me 0 NursingHome/LTC ❑ Hospice Facility
<br />0 ER/Outpatient 0 Decedent's Home
<br />❑ DOA ❑ Other (Specify)
<br />8b. FACILITY -NAME (If not Institution, give Street and number)
<br />Good Samaritan Hospital
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Kearney 68847
<br />8d. COUNTY OF DEATH
<br />Buffalo
<br />9e. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />- 9d. STREET AND NUMBER
<br />109 East Aston Ave.
<br />90. APT. NO
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />a YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH IRMarried 0 Never Married
<br />❑ Married, but separated 0 Widowed ❑Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Sandra Klimek
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Robert Milton
<br />12. MOTHER'S•NAME (First, Middle, Maiden Surname)
<br />Vicki Dekker
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes.
<br />(Yes, no, orunk.) No
<br />14a. INFORMANT -NAME
<br />Sandra Milton
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />• ([Burial ❑Donation
<br />❑ Cremation 0 Entombment
<br />❑Removal ❑ Other (Specify)
<br />16a. EMB IGNA
<br />16b. LICENSE NO.
<br />is S/0
<br />16c. DATE (Mo., Day, Yr. )
<br />August 22, 2009
<br />18d. CEMETERY, CRE A ORY OR OTHER LOCATION CITY / TOWN STATE
<br />St. Joseph's Catholic Cemetery Friend, Nebraska
<br />17a. FUNERAL HOMO NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />k A•fel Funeral Home 1123 West Second, Grand Island, NE
<br />r
<br />18. PART I. Enter the chain of events -diseases, injuries, or complications --that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE
<br />17b. Zip Code
<br />68801
<br />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: onset to death
<br />IMAEDMTECAUSE (Final (8) (724)j4,-fiaz. f j: 9i -es, .^
<br />ammo 0artdNonresulffnp DUE TO, OR AS A CONSEQUENCE OF: i onset to death
<br />:;: aldose')
<br />1
<br />Sequentially •Ilei conditions,8 (b) $1->�D r!i -/ /4„..„„.e . �2.�.>G, e �v eis-.rL. �.
<br />any4Ieedhgtote com9Med DUE TO, OR ASA CONS OUENCE OF: 1 onset to death
<br />_-. online'.
<br />{ EntertheUNDERLYNGCAUSE _
<br />°
<br />} (dw..ealrtmthetMated (0 6,1 • .9/ ,p��/d f L4fl y) 1-11'2‘1°--
<br />a?G
<br />4: In duth) DUE TO, OR AS A CONSEQUENCE F: 1 onset to death
<br />Off1
<br />(4 6Afrruz. u.4.41/4/C.� A�»itiji',N, v7/t=3ca
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Condition contributing to the death bot resulting in the underlying caus given In PART I.
<br />ApV,AAUCc/) 40a -046414y 4-1,Tq yt,,� DJs 4.4-s c (Md n 85 - A.4# b 5)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ;iffNO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />21a. MAN OF DEATH
<br />atural ❑ Homicide
<br />0 Accident❑ Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑Passenger
<br />21c.WASAN AUTOPSY PERFORMED?
<br />YES 0 NO
<br /><. s•
<br />❑ Not pragnantbut pregnant within 42days ofdeath
<br />0 Not pregnant but pregnant 43 days to 1 year before death
<br />[ ;:= 0 ilnknown i1 pregnant within the past year
<br />❑Suicide 0 Could 001 be determined
<br />0 Pedestrian
<br />Other (Spatia)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE
<br />COMPLETE CAUSE OF DEATH?
<br />,Ca..17ES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />.,- 22d.INJURY ATWORK?
<br />❑ YES ❑ NO
<br />ti ix;
<br />22e DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY- STREET 8 NUMBER, APT. NO. CITY/TOWN MATE ZIP CODE
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<br />23e. DATE OF DEATH (Mo., Day, Yr.)
<br />G L
<br />O•/ -1 • o C/�`t11
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<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b.TIME OF DEATH
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<br />lir
<br />.Q411
<br />24c.PRONOUNCED DEAD (Mo.,Day,Yr.)
<br />24d. TIME PRONOUNCED DEAD
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<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />1• 2s' -v r
<br />23c.TIMEOFDEATH
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<br />23d. To the best of my knowledge, death occur ed at Me time, dote and place
<br />and a the cause(8) stated. (Signature and Title) ♦
<br />•
<br />1 i i.3 24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />B 1 the time, dots and place and due to the cause(s) staled. (Signature and Title ) •
<br />•
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES QN0 0 PROBABLY 0 UNKNOWN
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES X NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a is NO 0 YES 20N0
<br />;?=;1.
<br />rte:
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Moshin Khan M.D. 123 West 31st St., Kearney, NE 68847
<br />28aREGISTRAR'S SIGNATURE
<br />fitifeitag d-
<br />28b. DATE FILED Byars, (yo.,206g
<br />A�uuuS 1 L�tjn�JJ
<br />HHS -61 11/03 (55061)
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