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<br />2f?4/lll)1)t tikl`�a . ,...f!tommtc .. pet IN
<br />STATE OF NEBRASKA
<br />x .+.a ntiyartet gage rearterrr+ asr affil It
<br />,` t a' 4Ub,S,r<: , 4rl ,))),.Pica.;,(!! 4 �h4rr44.:P
<br />Pr i444Ointriu5n :�%r%lrr11���ttl{��O tj4COr4,1%e
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<br />I+YNEN `mus COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />A; E OP: fSSU. .4NCE
<br />9/912024
<br />LINCOLM, NEBRASKA
<br />ill ..T.i
<br />202444546
<br />? 604-41.Atiller,
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />' DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE. OF DEATH
<br />1. tirECEDET4IT'S NAM>r: (First, Middle, Last, Suffix)
<br />John VHEIIlam 8uman Sr
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Pawnee City Nebraska
<br />T. SOCIAL SECURITY: R
<br />505-424801
<br />N►:IMeE
<br />Sb. FACILITY.NAME (If not institution, give street and number)
<br />8t0 East Delaware Avenue
<br />6� CITY CR TOWN OF DEATH (Include Zip Code)
<br />Grand Island, 66801
<br />8a. RESIDENCE -NATE
<br />IUebraska
<br />6d STREET AND NUMeaR
<br />810 East Delaware Avenue
<br />5a. AGE - Last Birthday
<br />IYrs•)
<br />.79
<br />5b. UNDER 1 YEAR
<br />MOS..:;
<br />DAYS
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF t?EA'CN #peD rp y 'I 3'
<br />February 1 016
<br />8a.PLACE OF DEATH
<br />HOSPITAL Q Inpatient
<br />0 ER/Outpatient
<br />9b. COUNTY
<br />Hall
<br />OTHER 0 Nursing Home/LTC
<br />IX1 Decedent's Home
<br />0 Other (Specify)
<br />Sd. COUNTY OF DEATH
<br />Hall
<br />Hospce FacHily ''
<br />Loa. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />O fRetrried Outteperstied 0 Widowed 0 Divorced 0 Unknown
<br />11 FATHER'S-NAME.,(First,` Middle, Last, Suffix)
<br />Melvin Joseph #uman
<br />9c. CITY OR TOWN
<br />Grand Island
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />ag pjSice CITY t iMiTS,;
<br />::M"VE15".'',D446,0
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />LaVonne lane 'Osborn;
<br />13: EVER IN U.S. ARMED FORCES? ,Give dates of service if Yes.
<br />{Yes No, or,.t$nk),Ye...S. 08/24/1954-08/11/1962
<br />15:REYNQO OF.DISPOSIT ON
<br />;Burial QDonatian
<br />©`Crematiot► ❑ ttttombment
<br />❑ Removal 0 Other (SpecHy)
<br />7a ;FUNERAL;
<br />Alt Faiths
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Anna Marie Brockmeier
<br />14a. INFORMANT -NAME
<br />LaVonne Ilene Buman
<br />16s. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />16b. LICENSE NO.
<br />1071
<br />14b. RELATNSHIP TO DECEDENT
<br />Spouse
<br />1
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />OME NAME: AND MA LING ADDRESS (Street, City or Town, State)
<br />unefia)Home; 2929 S. Locust Street, Grand Island, •Nebraska
<br />6e. DATE (MO r tIY`Yit .
<br />February y 4 216
<br />STATE.
<br />Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />tp: PART I, Entwine Chain of twins. elfireasts, injuries, or complications -that directly caused the death. DO NOT enter temmnal events such as cardiac arrest,
<br />"-
<br />!PP/ serest er va!nitsular flbfMtetton without showing the etiology. DO NOT AEQREVIATE. Enter only one cause on. line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />tIATE RAUSE (Finex 0) Respiratory Failure
<br />iys'or epntatfeii
<br />resulting
<br />Se quentMlg; ilst coindttialk1,
<br />mXkadinptOOSbowie beteg>.:
<br />APPROXIMATE INTO
<br />onsetfb>ds4fh
<br />1 Dau......'
<br />L
<br />online •
<br />Enter. file UNDERLYING CAUSE
<br />(disease or injury that inithaee
<br />:the *Mitt reauaing Inds.nih)
<br />DUE TO, DR AS A CONSEQUENCE OF:
<br />b)Congestive Heart Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />onset to dear
<br />'1f ...
<br />onset to;.r iiith
<br />DUE to, OR ASA CONSEQUENCE OF:
<br />d)
<br />onset 1:
<br />1$. PA:RTLIOTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in P
<br />Vascular Dementia
<br />20IP.'f044.14.404„
<br />Q. MpregnantwlbrMrpast.year
<br />❑'RreiMii n atSi.ee ofdeitth
<br />r❑^ Net pregnant, but pregnant within 12 days of death
<br />t pregnttn .but ptsg uiuint/4a days tot year before death
<br />Q t rtltndwn ifiYaenane wlMiifllha past year
<br />22a.:DATE'
<br />MIRY (21124
<br />;Yr.)
<br />21a. MANNER OF DEATH
<br />Natural ❑ Ndmicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide0
<br />22b. TIME OF INJURY
<br />21b.IF TRANSPORTATION INJURY
<br />Q Driver/Operator
<br />0 Passenger
<br />ART 1. 19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑YES ......: >:::
<br />21c. WAS AN AUTOPSY:PO
<br />❑ YES 63Nil ..
<br />21d. WERE AUTOPSYMorton
<br />Could not be determined o.FAVAILABLE
<br />TO COMPLETE cAUsi50p DEM* .:
<br />❑ YES 1:1)4.0,*"
<br />..;
<br />22c. PLACE OF INJURYAt horns, farm, street, factory, office building, construction alto, atg t$ Fecify)
<br />0 Pedestrian
<br />Q Other (Specify)
<br />22d. INJURY AT WORK?
<br />CATION OP It JURY STR
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />TA NUMBER, APT.NO. CITY/TOWN
<br />23e. DATE OF DEATH (Mo., Day, Yr.)
<br />February 1, 2016
<br />Iii. ( 'fE oNg0 (Mo D TO
<br />#Ft
<br />a
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEA
<br />Day. r. 23c. TIME OF DEATH
<br />Leal/ :C1016 01:05 PM
<br />extol my knowledge, death occurred at the time, date and place
<br />I t4the cause(p stated. (Signature end Title)
<br />Jennifer L. Brown, MD
<br />TOSACCei US•
<br />YE$
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRO
<br />Zee. On the basis of examination and/or Investigation, in my.opinion 4eeftD ie
<br />the time, date and place and due to the causes) stated, (Bipnstabe and
<br />OiYTRIBUTE TO THE DEATH?
<br />NArirE, TITtEANE)4lot
<br />Jennifer . Broin,
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />PROBABLYUNKNOWN
<br />EBS Oil CERT! IER (Type or Print
<br />0, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />RE/46Pratot Cow" -
<br />26b. WAS CONSENT
<br />Not Applicable If 26a is NO
<br />28b. DATE FILED BY REFI
<br />February 8, 2016
<br />
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