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<br />
<br />
<br />
<br />STATE OF NEBRASKA
<br />
<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 RIi~JJ.~ WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAn;j~,,~~'!YJ~/S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. "!; :\.......1~.. ". '1&,," ~~,
<br />. 11"11} i
<br />DATE OF ISSUANCE . . . ..' .."t. t
<br />
<br />JUN 0 6 ZOO8 200806 982 . ~ t1 fA'N . ...IVtCY'S~~Ps,;rt,.:>~
<br />LINCOLN, NEBRASKA .' ~~~1rBlf~I:~':"'IP!~ ;;
<br />
<br />STATE OF NEBRASKA. DEPARTMENT OF HEALTH AND HUM~S~~ J>r~r-;IG:'~
<br />CERTIFICATE FDA H " ft",'",t;..v, .........
<br />1. DECEDENrS-NAIIIIE (Flrsl, Middle, La.I, Suffix) 2. S . ~y,Yr')
<br />~...,"~'
<br />
<br />
<br />Harold J Green Jr
<br />
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE-La.1 Birthday 5b. UNDER 1 VEAR
<br />
<br />(Vrs,) MOS.
<br />Buck Grove, Iowa 76
<br />
<br />DAVS
<br />
<br />March 23, 1932
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />8a. PLACE OF DEATH
<br />HOSPITAL: IKIlnp.llonl
<br />o ERlOulp.llent
<br />ODOA
<br />
<br />o Ho.plce Facility
<br />
<br />lb. FACILITY-NAME (If nOllnalllulion, give .treeland number)
<br />
<br />~ 0 Nursing HomolL TC
<br />o Decedenl'. Home
<br />o OIhor(Spoclfy)
<br />
<br />507-34-6119
<br />
<br />Saint Francis Medical Center
<br />
<br />80. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />ge. RESIDENCE-STATE lb. COUNTY
<br />
<br />II.
<br />j
<br />"C
<br />81
<br />I;::
<br />'I:
<br />81
<br />i
<br />81
<br />Q.
<br />a
<br />o
<br />81
<br />CD
<br />o
<br />I-
<br />
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />I!I Ve. 0 No
<br />
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />
<br />Hall
<br />
<br />81. ZIP CODE
<br />
<br />2417 W. John
<br />10.. MARITAL STATUS AT TIME OF DEATH iii Married 0 Nevor Marriod lOb. NAME OF SPOUSE (Flrsl, Mlddlo, L.OI,
<br />o M.rried, bUI.eparaled 0 Widowed 0 Divorced D Unknown
<br />
<br />68803
<br />
<br />
<br />11. FATHER'S-NAME (Flrsl, Middle, L..I, SUffix)
<br />
<br />12. MOTHER'S.NAME (First, Middle. Maiden Sumeme)
<br />Gude
<br />
<br />Harold J Green Sr
<br />
<br />13. EVER IN U.S. ARIIIIED FORCES? Give d.le. of .e..lcelf Yes.
<br />
<br />(Vee, No, or Unk.) No
<br />
<br />15. METHOD OF DISPOSITION
<br />[iI Buttal 0 Donaiion
<br />
<br />D.Crematlon DSntombment
<br />o Removal 0 Other($pec:lfY)
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Wife
<br />180. DATE (Mo.. Day, Vr.)
<br />
<br />1 eb. LICENSE ND.
<br />:P/~.:?S-
<br />
<br />May 30, 2008
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />Westlawn Memorial Park Cemetery
<br />
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (Slrool, City or Town, SI.lo)
<br />Livingston-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />17b. Zip COde
<br />68803
<br />
<br />CAUSE OF DEATH (See instructions and examples)
<br />
<br />'111. PART I. Enter'th. t.M/I1 of QV6nt1 . dl"'/iII"', Injurl.... or compUutlonl- thlt cnNctlt CIIuMd tn. dMth. DO NOT .mer te""JrNlleventl such I' cardllc. II'f'Ht,
<br />n!l5pilllf.ory arrest, Dr ventricular fibrillation wltho~t s.h9w1ng tl'l..Iil~loIQaY. 00 .NOT ABB"'~VIATE. Ente.. only one GaUS8 on a IIn8. A.dd additional 11r1es It nec8!11sary_
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />
<br />.)~m
<br />
<br />I APPROXIMATE INTERVAL
<br />
<br />I on.el to dealh
<br />I
<br />:'2
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />dI....a Dr condition resulting
<br />In doalh)
<br />
<br />
<br />
<br />~
<br />
<br />S.quentl.lly 11.1 condition., W
<br />any, leading to the cause listed
<br />on line B.
<br />
<br />DUE TO. OR AS A CONSEQUENC
<br />
<br />"--~'-~~'S~h~_~
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF,
<br />
<br />I onsett
<br />I
<br />I
<br />I
<br />I
<br />
<br />
<br />Enter Ihe UNDERL VING CAUSE c)
<br />(dl..... or Injury Ihat Inilialed
<br />Ih. ..enle ...ultlng In dealh) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />
<br />. onset to death
<br />I
<br />I
<br />I
<br />I
<br />
<br />d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Condltlon. conlribullng 10 Ihe delllh but nol re.ulllng In Ihe undorlylng c.u.e given In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />D YES ~O
<br />
<br />a::
<br />w
<br />ii:
<br />~
<br />UJ
<br />o
<br />j
<br />i
<br />J
<br />
<br />20. IF FEMALE,
<br />o Not progn.nt within p..t y..r
<br />D pregn.nl .1 time of dealh
<br />D NOI pregn.n~ bUI pregnanl wilhin 42 dey. of de.lh
<br />o Not pregnant, but pl1lgnllnt 43 days to 1 year before death
<br />D Unknown if pregnanl within the posl ye.r
<br />
<br />21., MANNER OF DEATH
<br />~lur.1 0 Homlcld.
<br />D Accld.nl D Pending In....llg.llon
<br />D Sulcld. D Could nol be delermined
<br />
<br />21b.IF TRANSPORTATION INJURV
<br />D Driver/Oparalor
<br />o pas.anger
<br />o Pad..trian
<br />o Olh.r (Specify)
<br />
<br />21c, WAS AN AUTOPSV PERFORMED?
<br />
<br />DYES Cpie
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />
<br />DYES ~
<br />
<br />I- DVES DNO
<br />
<br />
<br />22a. DATE OF INJURY (Mo., D.y, Yr.)
<br />
<br />22bc TIME OF INJURV 220. PLACE OF INJURY-AI hom., f.rm, .lre.l, f.Clory, olnco building, oon.truotion .Ite, elo. (Speolfy)
<br />
<br />81
<br />CD
<br />
<br />INJ~I.!lY ~~. ~QRK? c
<br />
<br />22f. LOCATION OF INJURY - STREET & NUMBER. APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo.. D.y, Vr.)
<br />May 27, 2008
<br />
<br />248, DATE SIGNED (Mo., Day, Vr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />z>-
<br />:G'~W
<br />'to iii~
<br />~?i~ >-
<br />...ll.. <( ..J
<br />~ ~~ ~
<br />Z~~
<br />~li)8
<br />0...
<br />(,lo
<br />
<br />m
<br />
<br />24<:. PRONOUNCED DEAD (Mo.. Ooy, Vr.) 24<1. TIME PRONOUNCED DEAD
<br />
<br />a m
<br />
<br />m
<br />
<br />24e. On the basis of .xamln.tlon and/or Investlgatlonj In my opinion death occurred
<br />.11h.llm., d.t. .nd pl.c, .nd due 10 Ihe couse(.) elated. (Slgnalure .nd TlIlo)
<br />
<br />26.. HAS ORGAN OR TISSUE ~TION BEEN CONSIOERED?
<br />D YES [f" NO
<br />
<br />26b. WAS CONSENT GRANTED?
<br />No. Appllc.bl. W 26. I. NO D YES ~NO
<br />
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHVSICIAN OR COUNTY ATTORNEY) (Typ. or Print)
<br />Dr Ryan D Crouch DO 800 Alpha Grand Island, He
<br />
<br />68803
<br />
<br />26a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />
<br />26b. DATE FILED BY RIOGISTRAR (Mo., Doy, Vr.)
<br />
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