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STATE OF NEBRASKA
<br />r WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH,dA1tVD Ff~l~l,~t•~ VICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORb ON FILE WITH THE NEBRA RP~~f~ F~E;4LTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICM IS THE LEGAL DEPOSITORY Ft3R .~~ ECS ''~
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<br />DATE OF ISSUANCE \
<br />AUG 0 7 2009 ~sr~r jc~drsr ~v~ ' `~~
<br />2 0 0 9 o s 2~~ ~.l?~'P,~'lL~~T ~~ H~~~~ ~;
<br />LINCOLN, NEBRASKA 15tIJ~1Rt'b~a~Ei~1/ICE~~ "` ~ 'rr M'
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<br />STATE OFNEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPP~~y4`~`f ~ `~ ~ " ~
<br />C`IFRTIFIr_ATF f1C ~1CAT41 t G`~ "~~~~~ ~ t
<br /> t. pECEOENT'S•NAME (First, Mlddle, Last, 5ulllx) 2.9EX I 3. DATEOFDEATH (Mtl.;Oay,Yr.)
<br /> Jphn Neil _Hu has Male 7/31/200
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY of BIRTH 5a. AGE-Last Birtndey 5b. UNpER 1 YEAR 5c. UNDER 1 DAY 6. DATE pF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINE.
<br /> Howard Ctaunty, Nebraska
<br />_ 84 8/18/1924
<br /> 7. SOCIAL SECURITY NUMBER Be. PLACE OF DEATH m
<br /> 506-20-3020 HOSPITAL: ^Inpatient 4iliF8: ~I Nursing Home/LTC ^HCSpice Facility
<br /> 8b. FACILITY-NAME (If net Instltutlan, glue elreet antl number)
<br />^ ER10ulpallenl ^ Decadent'e Home
<br /> Tiffany Square Care Center ^ LYA ^ Other(Speclly)
<br /> Bc. CITY OR TOWN OF DEATH (Include Zlp Cade) ed. COUNTY OF pEATH
<br /> Grand Island Hall
<br /> 9a. RESIDENCE-STATE Ab. COUNTY 9c. CITY OR TOWN
<br /> Nebraska Ha?l Grand Island
<br /> 9d. STREETAND NUMBER ge. APT. NO 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> 302p West Ngrth Front Street _ 6$803 ~ 7~ Yes ^ No
<br /> t0a. MARITAL STATUS AT TIME OF DEATH ~ Married ^ Never Married 1gb. NAME OF SPgUSE (First, Mitldle, Lest. Sunix) It wife, glue maiden name.
<br /> ^ Married, but separated ^ Widowed ^ Divorced ^ Unknown E111111a Fellows Trull
<br /> 11. FATHER'S•NAME (First, Mlddle, Last, Su11i X)
<br />--....... __ .7amea 12. MOTHER'S•NAME (Flret, _ ~ Middle, Malden Surname)
<br /> 13. EVER IN U.S. ARMEq FORCE ? Glve dates of service if yes. t4a. INFORMANT•NAME 146. RELATIONSHIP TO DECEDENT
<br />es 1129/1948 ] /10/ 950
<br />, (Yea, no,tlrunk.) Y
<br />hes
<br />Emma Hu
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<br />-- ......
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<br />75. METHOD OF DISPOSITION f8a,EMeALMER-SIGNATURE 16b. LICENSE ND. 18c. DATE (Md., pay, Yr. )
<br /> ^Burial QDOnatltln not embalmed ----
<br /> ~' Crematicn ^ Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> ^9emoval C]other(specuy)
<br /> Westlawn Memorial Park Crematory grand Island NE
<br />
<br />~ 17a. FUNERAL HOME NAME AND MAILINp ADDRESS (Street, Clty Or Town, State) -. ~ 17b. Zip Cade
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<br />~,, Apfel Funeral Home 1123 West 2nd Street Grand Island, Nebraska 68801
<br />),.
<br /> 18. PART I. Enter the ghgylygf events••dlseases, In(urles, or cdmplications••that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br /> respiratory erree6 or ventricular fibrillation without ehtlwing the etiology. DO NOT ABBREVIATE. Enter Only one cause on a line. Add additlCnal Ilnag II nBCeaeary. I
<br /> IMMEDIATE CAUSE:
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<br />n9at td death
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<br />(a) ~
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<br />~ IMMEDIATE CAUSE (final
<br />\ M4~'R.~
<br />t~l'biL
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<br /> dlaeasewcondltlonresufting DUE TO, OR AS A C SSgU6NCE OF: I onset to death
<br />~, w in death)
<br /> I
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<br />'
<br />3equemlally Ilat condltlons, if ~, ~' (~ I 1 ~ ~ s
<br /> . ,
<br />eny,leadingtathecauaelleted DUETD,ORA ACONSEDUENCEOF: _~_ I Oneletlodetn
<br /> on line a.
<br />~ Enterthe llNDERLYIND CAUSE I
<br /> (dlseaceorln(urythatlnltiatad (c) I
<br /> .., .I .
<br />theevenureeukinglndeetn) DUETp,gRASACONSEDUENCEOF: __ I onaettodeath
<br /> LASE
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<br />1 (d) I
<br /> 18. PART IL OTHER SIGNIFICANT CDNDITIONS•Condltlona Contrlbuling t0 the death but net resulting In the underlying Cause given in PART I. 13. WAS MEDICAL EXAMINER
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<br />
<br />"
<br />~~, OR CORONER CONTACTED?
<br />~. ^ YES ^ NO
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<br />~` 26. IFFEMALH: 21a,MA NEROPbEATH 21b.IFTRANSPORTATIDNINJURY 21 C. WAS AN AUTOPSYPERFORMEp?
<br />^
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<br />F atural ^ Homicide
<br />Driver/Operator (~/
<br />^ Nal pregnant within past year
<br />^
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<br />^ Pregnant at time of death ^ Accldent^ Pending Investigation ^ Passenger
<br />~~~~• ^ Not pregnant, but pre nant within 42 tle s o1 death ^ Pedestrian
<br />g y ^ Suicide ^ Could nOt by determined 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />_
<br />- ^ NoNpregnent, but pregnant 43 days to 1 year belore death ^ other (Speclly) COMPLETE CAUSE
<br />OF
<br />DEATH?
<br /> ~~
<br />//
<br />^ Unknown if pregnant within the pest year _ DYES Y67N0
<br />~ Y.
<br />;., -
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<br />JURY (Ma, Day, Vr.) 22b. TIME OF INJURY 22c. PLACE OFINJURY-qt home,. farm. street, factory, o11ICe building, conetructlon site, etc. (Specify)
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<br />..~...._. ~..---- --
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<br />22d.INJURY AT
<br />RK?
<br />WO ~._~._
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<br />22e. DESCRIBE HOW INJURY OCCURRED
<br /> ~
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<br />^ YE5 ?'~ NO
<br /> 221.LOCATIpN OFINJURY-STREETd NUMBER, APT NO. CITYnOWN ___.. Y STATE ZIP CODE
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<br /> 23a. PATE OF DEATH Mo
<br />. ......~. ---
<br />( Day,Vr.) s 24e.DATE3IGNE0 (MC.,pay,Yr.) 24b.TIMEOPDEATH
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<br />$ar m
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<br /> _.
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<br />23b.DATESIGNED(Mo.,Day,Yr.) 23FTIMEOFDEATH ~~ 24c.PRONOUNCEDDEAp(Mt1.,Day,Yr.) 24d.TIMEPRONOUNCEDDEAD
<br /> co ,1,4 !~, So m pig m
<br /> ~ 'v 23d. To the deaf of my knowledge, death dccurred at the lime, date nd place ~ ~w ~ 24e. On the beets of examination and/or investigation, In my opinion death occurred at
<br />~
<br /> ue l0 t use(s) s/toted. (Signature and Title) • .
<br />~ the lime, date and place and due to the cause(s) elated. (Signature end Title)
<br /> ~~ •~ V
<br />.,' , 25. DIDTOBgC USE CONTRIBUTETOTHEDEATH? 28a. HAS ORGAN OFTISSUE DONATION BEEN CONSIDERED? 28b. WA9 CONSENT GRANTED?
<br />t ~ ~
<br />^ YE5 f3Nq L7 PROBABLY ^ UNKNOWN
<br />^ YES ;L1rN0
<br />Nat Applicable if 28a Is NO ^ YES ~ NO
<br /> 27.NAME,TITLEAND ADDRESS OF CERTIFIER (PHYSICIAN,CORONER'5PHYSICIAN OR COUNTY ATTORNEY) (Type orPrinQ
<br /> Ryan A. Crouch 800 Alpha Street Grand Island, Nebraska 68803
<br /> 28a. REGISTRAR'S SIGNATURE 26b. bATE PILED BY REGISTRAR (MC„ pay, Yr.)
<br />I ~ , AUG 5 2009
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<br />HHS-61 11/03 (55061)
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