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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND H
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBt $KA4rE 2
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOI jIt';'
<br />DATE OF ISSUANCE
<br />01/30/2014
<br />202009 707
<br />AF 'SERVICES, IT CERTIFIES
<br />HEALTH AND
<br />i,r
<br />LINCOLN, NEBRASKA �o'`d y .J SERVICE:
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN441:4
<br />CERTIFICATE OF DEATH 0,e
<br />To be completedlvertfted by: FUNERAL DIRECTOR I
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)2.^$EX',
<br />James Dale McComb
<br />{
<br />lave \
<br />17S f' 114114 Dqr;
<br />,��Janl)iuy,2,3�014
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 SAY
<br />4 DATE OF BIRTH (Mo., Day, Yr.)
<br />Coin, Iowa
<br />(Yrs.)
<br />77
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINIL
<br />June 26, 1936
<br />7. SOCIAL SECURITY NUMBER
<br />505-38-5721
<br />6a. PLACE OF DEATH
<br />mom 0 inpatient gnu 0 Nursing Home/LTC ❑ Hospice Fadilty
<br />8b. FACILITY -NAME (H not Institution, give street and number)
<br />316 Comanche Avenue
<br />0 ER/Outpatient ® Decedent's Homo
<br />❑ DOA ❑ Other j8pi11Y)
<br />8e. 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 />316 Comanche Avenue
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />al 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, give Malden name
<br />Bette Jean Millspaugh
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Raymond McComb
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Frances Searle
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service N Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Bette Jean McComb
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />1eb. LICENSE NO.
<br />15c. DATE (Mo., Day, Yr.)
<br />January 23, 2014
<br />® Cremation ❑Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY 1 TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. 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 Cods
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />To be completed by: CERTIFIER
<br />1
<br />11. PART I. Enter the chain of events-dlseues, Injuries, or complicadonsahat dlncty caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />rapir■tory arrest, or ventricular fibrillation without shoving the etiology. 00 NOT ABBREVIATE. Enter only one cause on • line. Add additional Dna M neceseuy.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Respiratory Failure
<br />disease resulting
<br />' APPROXIMATE INTERVAL
<br />onset to death
<br />Minutes
<br />or conaidon
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />Sequentially lit conditions, It b) Myocardial Infarction I Minutes
<br />any. 'siding to the cause listed I
<br />I
<br />on 11th a' DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />Enter the UNDERLYING CAUSE C) 1
<br />(disease or Injury that initiated
<br />the events resulting in death► DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />LAST d) 1
<br />I
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART 1.
<br />Chronic History Of Heart Problems, Diabetes And Lung Cancer
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ NO
<br />20. IF FEMALE:
<br />0 Not pregnant withbr put year
<br />❑ Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homkla
<br />0 AccldeM 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Pasieng.r
<br />21C. WAS AN AUTOPSY PERFORMED?
<br />0 YES El NO
<br />Pedestrian
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />❑ Not Pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregaa 43 days to 1 year before death
<br />❑ Unknown N pregnant within the pest year
<br />0 Suicide 0 Could not be determined
<br />❑
<br />❑ Other (Specify)
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22e. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, Af T.NO. CITY/TOWN STATE ZIP CODE
<br />s I3
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />January 27, 2014
<br />24b. TIME OF DEATH
<br />Approx. 0?:30 AM
<br />6January
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />J
<br />5
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />23, 2014
<br />24d. TIME PRONOt/NCED DEAD
<br />02:59 AM
<br />1
<br />23d. To the beet of my knowledge, death occurred at the aha, ate and place
<br />E
<br />g
<br />24e. On the basis of examination and/or investigation, In my opinion Bath occurred at
<br />due the TIlle)
<br />ie
<br />and due to the cause(s) shad. (Signature and TRIO
<br />le a
<br />the time, date and place and to cause(s) stated. (signature and
<br />Jon Hendricks, Hall Deputy County Attorney
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? II28a. HAS ORGAN OR
<br />0 YES 0 NO 0 PROBABLY ® UNKNOWN 0 YES
<br />MOE , TION BEEN CONSIDERED?
<br />•
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable H 28a 1s NO ❑ YES q NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jon Hendricks, Hall Deputy County Attomey, 231 S. Locust, P.O.: • • Grand Island, Nebraska, 68802
<br />r
<br />281. REGISTRAR'S SIGNATURE S I Cvo
<br />2eb. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 28, 2014
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