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<br />JUN 04 2008
<br />LINCOLN, NEBRASKA
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NESRASKA HEALTH ANJJJ<<MMt/;~E.RVICES
<br />SYSTEM, "CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL.:1Il'CQfIPt{J/t1.lJ.li'f/TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAUSTf,C$.'fR;l:fi(iN;. t!fJJJJH JS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS, _P' ~'( ,"~~(h ~">"'<""
<br />
<br />~ '/lv-e'
<br />DATE OF ISSUANCE _-' :: : '. ". .~.
<br />200805087 e .-=: EY;S.-SOOFitfl! .--
<br />A~.4N,tJ;1ArAEJ~l$TR:Att ~-~_
<br />HSAt.fJ4.AND .HUMANSERVI~ ~,-
<br />~;-.o 1# ' i')- -,'
<br />
<br />.'"""1. STATE OF NEBRASKA - DEPARTMENT ~rEALTH AND HUMAN dR~I~Glt, r'.'A;t:,':~:J
<br /> \ LP'K F ~liiaTIoI "'-",_ "" ji.. ',' ,'I:;: 1 1
<br /> 1. DECEDENT'S-NAME (Firat, MI~~lo, Loot, sum>) 2. SEX l:.:./~ I~:,~ .' .' ,- o:;a..,w.....
<br /> ,
<br /> \ ~..: ,~ --.
<br /> Harry Todd Crittenden Male Mev 1'8, 2008
<br /> 4. CITY AND STATE OR TERRlTORV, OR FOREIGN COUNTRY OF BIRTH 50. AGE-Laot Blrthdoy 5b. UNDER 1 VEAR 5<:. UNDER 1 DAV 5. DATE OF BIRTH IMo., Doy, Vr.)
<br /> IVra.) MOS. I DAYS HOURS I MINS.
<br />" Wichita, Kansas 76 May 14, 1932
<br /> 7. SOCIAL SECURITY NUMBER 5.. PLACE OF DEATH
<br /> 0::: 511-24-1962 IlQ&elIAL;, 0 Inp.tlont QIlWt Il!I Nursing Homo/LTC o Hooplco Focillty
<br /> I:! 8b. FACIUTY-NAME (If not Inolltullon, glvo otreet and numbor) o ERIOutpollont o De<:odonr. Home
<br /> ld DDOA o OthortSpoclfy)
<br /> 0::: VA Medical Center-Grand Island
<br /> is
<br /> ..I 8c. CITY OR TOWN OF DEATH (Includo Zip Codo) 18d. COUNTY OF DEATH
<br /> ffi Grand Island 68803 Hall
<br /> z ta. RESIDENCE-$TATE I tb. COUNTY T8C. CITY OR TOWN
<br /> :::)
<br /> II.
<br /> j Nebraska Hall Grand Island
<br /> 1: td. STREET AND NUMBER I to. APT. NO. Illf. ZIP CODE T tg. INSIDE CITY ur;IITS
<br /> IE 1908 W. Charles 68803 ~ v.. 0 No
<br /> t lOa. MARITAL STATUS AT TIME OF DEATH liD Monlod D Noyor MOrrlo~ll0b. NAME OF SPOUSE (Flrsl, MI~dle, Laot. SufIl>) " wife, give mal~n name.
<br /> D Marrlo~, bul ..porslod D Widowed o Dlvorcod D Unknown Betty Lou McCoy
<br /> Q. 11. FATHER'S-NAME (Flrsl, Mlddlo, Lalltl Sumx) 11~. MOTHER'S-NAME (First. Mld~lo, Maldon Surname)
<br /> S
<br /> u John Crittenden Ruth Miller
<br /> .z 13. EVlaR IN U.S. ARMED FORCES? GIYO ~ol.a oreorYlcoll YU.\148.INFORMANT.NAME 14b. RELATIONSHIP TO DECEDENT
<br /> ~ (V.a, No, or Unk.) Yes 08/27/1 !l53-06/08/1955 Bettv Lou Crittenden Wife
<br /> 1 &: METHOD OF DISPOSITION 1&8. EMBALMER-SIGNATURE I 1&b. LICENSE NO. 15<:. DATE (Mo., Day, Yr.)
<br /> osurtol ODoMlion Not Embalmed Mav 19, 2008
<br /> IiiI crematlen OEntombment 15d. CEMETERV, CREMATORY OR OTHER LOCATION CITYfTOWN STATE
<br /> o Remow.l DOtIl.~.peclfyJ
<br /> Central Nebraska Cremation Service Gibbon Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slreot. City or Town, Statal 17b. Zip Codo
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> CAUSE OF DEATH (See instructions and examples)
<br /> 11. PARr I. Enter tM c~11t of .Vtit6- - dIHII.... Injul1... or I:ampllcmlol'l.~ that dlreiOCty (:tIu.d tIN dMth. DO NOT enter tennlMI .wfIUI .uch .. CfItdile arrest,. I APPROXIMATE
<br /> INTERVAL
<br /> ....pltatOty ......IC. or ventrtc:Q..... fibrillaUon WIthout .howlng.... etiology. DO NOT ABBREVlATE.. Enter only one cau" on .IIJH1. Add addnlonalIInuIf nee....,.. I
<br /> IMMEDIATE CAUSE: onoot to doolh
<br /> IMMEDIATE CAUSE (Flnol I 5/1r log
<br /> dl..... or condition ....ultlng 0) Cardio pulmonary arrest I
<br /> In doalh)
<br /> DUE TO, OR AS A CONSEQUENCE OF: on..t to death
<br /> I wed5
<br /> Sequontlally 1I0t condlllona, II b) Dehydration I :L
<br /> any, leading to the cause lI.ted
<br /> on IIno a. DUE TO. OR AS A CONSEQUENCE OF: onlot to duth
<br /> I
<br /> Entor tho UNDERLYING CAUSE c) Poor oral intake 'S/IJ/br: (J.."J, I
<br /> (dlo.ao. or Injury that Inlllolod DUE TO. OR AS A CONSEQUENCE OF: on.ello death
<br /> tho 0_ relultlng In doolh) I
<br /> LAST ~ '310~ (A m.o...~
<br /> d) Pancreatic cancer
<br /> 18. PART II. OTHER SIGNIFICANT CONDITIONS-Condlllona contributing to th. dealh bUI not multlng In tho undor1ylng caulo glvon In PART I. 1&. WAS MEDICAL EJ(AMINER
<br /> OR CORONER CONTACTED?
<br /> DYES tJ NO
<br /> 0:::
<br /> W ~.IF FEMALE: 218. MANNER OF DI!ATH 21b. IF TRANSPORTATION INJURY ~lc. WAS AN AUTOPSV PERFORMED?
<br /> Ii: ONot pragnant within put yoor IX Natural o HomICide o Dr1yortOpar.tor DYES ~NO
<br /> ~
<br /> W o Pregnant at time of death D Accldonl 0 P.ndlng Inyootlgollon D P....ngor 21~. WERE AUTOPSY FINDINGS AVAILABLE
<br /> U D NOI pragn.nt. but Prollnonl within 42 dayo 01 doolh o Sulcldo o Could not bo dOlOrmlnod o Po~.trlon TO COMPLETE CAUSE OF DEATH?
<br /> j o Not prsgnant. bul pragnent 43 dayo to 1 ye.r before doath o Othor (Sp.clfy) DYES oNO
<br /> i oUnknown II pregnant within tho pul year
<br /> ii I ~~b. TIME OF INJURV I Uc. PLACE OF INJURY-AI home, form, olrool, lactory. offico building, conalnlctlon olio, ole. (Specify)
<br /> E 220. DATE OF INJURY (Mo., Doy, Yr.)
<br /> 0
<br /> U
<br /> ~ 2~. INJURY AT WORK? 22.. DESCRIBE HOW INJURY OCCURRED
<br /> 0
<br /> l- DyES oNO
<br /> ~~. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITYfTOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day. Yr.) .:~i:i 24a. DATE SIGNED (Mo., D.y, Yr.) 24b. TIME OF DEATH
<br /> Z 18,
<br /> '::$ May 2008 m
<br /> u !.!i:l
<br /> I~>- ~3b. D7~ SIG,i.;D (Mo., Day, Yr.) I ~3c. TIME OF DEATH ~ mO 24c. PRONOUNCED DEAD (Mo., Doy, Yr.) 24<1. TIM!! PRONOUNCED DEAD
<br /> 5 19 ;)00 <7 06:57 A.m ~~ >-
<br /> l:I.lt.... jilLol;l m
<br /> a g>~ ~ ~~ 0
<br /> ....- Ud. To tho bell 01 my knowl~go, d.alh occurro~ lit tho limo, dalo .nd placo "'w 24e. On th. bul. of admlnatlon .ndlor Inveatlgatlon, In my opinion death oCCUrntd
<br /> !1! an~U~I01J:::g~ndTltlO) 11 Z;;;l .1 tho limo, dota ond placo and duo 10 tho cauu(I)ltatod. (Slgnolure and Tltlo)
<br /> ~! 000
<br /> \ I- tt:U
<br /> 0..
<br /> UO
<br /> ~ ~5. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 1260. HAS ORGAN OR TISSUE DONATION BE!!N CONSIDERED? I ~&b. WAS CONSENT GRANTED?
<br /> all YES 0 NO D PROBABLY D UNKNOWN D YES 11\ NO Nol Appllcablo " ~60 10 NO D VES iJ NO
<br />\ 2? NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typo or Prlnl) Island,NE
<br />Heidi Tetherow, MD-VA Medical Center 2201 N. Broa~well Ave.Grand
<br /> hJl~ rl-~
<br /> 280. REGISTRAR'S SIGNATURE At:t~ t 1 (~..~. 28b. DATE FILED MAyGISiRtf (iMa' Yr.)
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