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<br />
<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL R~F~I.E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSL~ SliB,..'A~JCf/'1IqJJS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ..I ~1;.~' -;~ II. jj j
<br />.... \\T~fi> J.,
<br />DATE OF ISSUANCE :.JI ..l.J;....' ~.' ".".,,', -(. .'.
<br />JUN 0 G 2008 2 0 0 8 0 5 0 3 5 0" '.' ~ :'<. /ANt:er-1i.;:CI!JJC:j~)".
<br />Aj;S1jrANTff7MEIl'i;t~tMtf:.~;
<br />LINCOLN, NEBRASKA Hf!\aH: ~NftftllI!~Ijf<<;J~,>
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMA~\~~~ft""';';:'/Y\";"')ci~:e...
<br />CERTIFI DEATH " ": ',.r:~ .. .,'tJ....ud;1Q;
<br />1.DECEDENrS-NAME (Flrsl, Mlddl., La.I. Suffix) 2.S x .\'J'" '. ,:...~'9F',~ ' ,..Day,Yr.)
<br />~I"'" "." '. t. ',..f""","~\: "-
<br />Harold J Green Jr Male"~ ." May 27,'200s-'"
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 50. AGE-Lol Birthd.y 5b. UNDER 1 YEAR 5c.UNDER 1 DAy.t.Q...re,o'j:'flll~TH (Mo.. Doy, Yr.)
<br />
<br />
<br />(Vrs.)
<br />
<br />MOS.
<br />
<br />HOURS MINS.
<br />
<br />DAVS
<br />
<br />Buck Grove, Iowa
<br />7. SOCIAL SECURITY NUM6ER
<br />
<br />76
<br />
<br />March 23, 1932
<br />
<br />So. PLACE OF DEATH
<br />HOSPITAL: IXIlnpoll.nl
<br />o ERlOulpollenl
<br />o DOA
<br />
<br />507-34-6119
<br />
<br />QIliIR; 0 Nursing Home/LTC
<br />o Dec,denrs Home
<br />
<br />o Ho.plc. Feclllty
<br />
<br />Sb, FACILITY-NAME (If nOlln.tIIullon, give elreel.nd number)
<br />
<br />o Other{Sp.clfy)
<br />
<br />Saint Francis Medical Center
<br />
<br />Sc. CITY O~ TOWN OF DEATH (Includ. Zip Code)
<br />Grand Island 68803
<br />
<br />8d. COUNTY OF DEATH
<br />
<br />9.. ~ESIDENCE-STATE
<br />
<br />8b. COUNTY
<br />
<br />
<br />68803
<br />
<br />II.
<br />
<br />Nebraska
<br />
<br />Hall
<br />
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<br />.....
<br />
<br />9<1. ST~EET AND NUMBER
<br />
<br />81. ZIP CODE
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />I1iI Ve. 0 No
<br />
<br />2417 W. John
<br />
<br />10e. MARITAL STATUS AT TIME OF DEATH iii M.rri.d 0 N.ver Morrted 10b. NAME OF SPOUSE (Flrsl, Middle, Loel, Suffix) If wi f., glv. melden neme.
<br />
<br />o Marrt.d, bul .eperaled 0 Widowed 0 Divorced 0 Unknown
<br />
<br />
<br />11, FATHER'S-NAME (Firsl, Mlddl., L..~ Suffix)
<br />
<br />12. MOTHER'S-NAME (Flrs~ Mlddl., Mold.n Sumome)
<br />Gude
<br />
<br />Harold J Green Sr
<br />13. EVE~ IN U.S. ARMED FORCES? Glv. doles of servlc. if Y.s.
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />16b. LICENSE NO.
<br />4P-H,;;>S-
<br />
<br />Wife
<br />16c. DATE (Mo.. Doy, Vr.)
<br />
<br />May 30,2008
<br />
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />[iI,Burial DOonatlon
<br />o Cl1Imatlon 0 ISntombmont
<br />o ......v., OOlhertS".'lyl
<br />
<br />STATE
<br />
<br />CITYffOWN
<br />Grand Island
<br />
<br />Nebraska
<br />17b. Zip Cod.
<br />68803
<br />
<br />Westlawn Memorial Park Cemetery
<br />
<br />170. FUNERAL HOME NAME AND MAILING ADDRESS (Slrsel, City or Town, SIOI.)
<br />Livingston-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />
<br />CAUSE OF DEATH (See instructions and examples
<br />
<br />1'. PART I. Enter tll. ch~'" or ItWtItI . dlseaa.., irljurtt., or c:ompIlGlo"o"s. Il1at dirBCtJy cauMd the death. DO NOT enter tennlnal.vent& Bu~h as can::Uac a,,.,,,
<br />....plratory amllit, 01' wntrieular fibrillation wlthc,ut showing thtll etiOlogy. 00 NOT ABBREVIATE. E:nt.r only one CBUBe un a IIn.. Adcllddltlonlllln._11' QacItllAty'.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />sl~m
<br />
<br />I APPROXIMATE INTE~VAL
<br />I
<br />I onset to death
<br />,
<br />I
<br />
<br />IMMEDIATE CAUSE (Fino'
<br />dls.a.. or condition rasultlng
<br />In dealh)
<br />
<br />2
<br />
<br />
<br />I onset to death
<br />
<br />i 'Z ~
<br />
<br />SequentlBlly list condltlonsl If
<br />any, leading to th. cauBolisted
<br />on line B.
<br />
<br />DUE TO, OR AS A CONSEQUENC
<br />
<br />,~-~~~D~~.-~~
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I onset t death
<br />,
<br />I
<br />I
<br />,
<br />
<br />Enterth. UNDERL VING CAUSE c)
<br />(dl..... or Injury Iha'lnlllsled
<br />the evenle rsaulllng in d.ath) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />
<br />I onset to death
<br />I
<br />I
<br />I
<br />,
<br />
<br />d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions con.ribullng 10 Ihe d.alh bul not re.ulllng In .he underiylng cau.. glv.n In PA~T I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />o YES ~O
<br />
<br />0::
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<br />
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<br />CI.
<br />E
<br />o
<br />u
<br />&l
<br />o
<br />.....
<br />
<br />20. IF FEMALE:
<br />D Nol prsgnonl wllhln pasl yeer
<br />o Pregnanl elllme of d.alh
<br />o Not pregnant, but pregnant within 42 days of death
<br />o Nol pregnenl, bUI pregnonl43 day. 10 1 y.ar b.fore d.olh
<br />o Unknown if pregnant within the past year
<br />
<br />21e. MANNER OF DEATH
<br />~urBI 0 Homic;lde
<br />o Accld.nl 0 P.ndlng Invesllgallon
<br />o Suicide 0 Could not be detennined
<br />
<br />21b.IF TRANSPO~TATION INJURY
<br />o Driver/Op.rator
<br />o P....nger
<br />o Pede.lrien
<br />o Olher (Specify)
<br />
<br />21c. WAS AN AUTOPSV PERFORMED?
<br />
<br />DVES ~
<br />
<br />21d. WE~E AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />
<br />DYES ~
<br />
<br />22e. DATE OF INJURY (Mo.. Day, Yr.l
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURV-AI hom., ferm, .lre.I, faclory, olllce building, con.trucllon .lle, elc. (SpeCify)
<br />
<br />22d.INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCU~RED
<br />
<br />OVES ONO
<br />
<br />2:lf. LOCATION OF INJURV - STREET & NUMBER, APT. NO.
<br />
<br />CITVfTOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />
<br />24b. TIME OF DEATH
<br />
<br />240, DATE SIGNED (Mo., Day, Yr.)
<br />
<br />23a. DATE OF DEATH (Mo., Dey, Yr.)
<br />May 27/ 2008
<br />
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<br />'" oz
<br />-IX
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<br />",11.< ....
<br />a ~~ ~
<br />"wz
<br />1: ~8
<br />~8~
<br />
<br />m
<br />
<br />24<:. PRONOUNCED DEAD (Mo., Day, Vr.) 24d. TIME P~ONOUNCED DEAD
<br />
<br />a m
<br />
<br />m
<br />
<br />248. On the basi. 01 examination .ndlor Inv..ligation, in my opinion death occumlld
<br />at th. 'Ime, date and place and du.to Ihe couse(.) .Ialed. (Slgnalure and Till.)
<br />
<br />28b. WAS CONSENT GRANTED?
<br />Nol Applicable If 28a Is NO 0 YES [B1.lo
<br />
<br />280. HAS ORGAN OR TISSUE ~TION BEEN CONSIDERED?
<br />~R08ABLV 0 UNKNOWN 0 VES (J" NO
<br />
<br />27. NAME, 1tTLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHVSICIAN OR COUNTY ATIORNEY) (Type or Prinl)
<br />Dr Ryan D Cr9uch DO 800 Alpha Grand Island,
<br />
<br />Ne 68803
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />
<br />28b. DATE FILED BY REGISTRA~ (Mo., Dey, Vr.)
<br />
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<br />
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