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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA .DEPARTMENT OF HEALTH ANG~„F~;.SSERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASK.~,'®~'PAR E(V1` ~?,F /-IEAITH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR Vl,~XI(~Ri~'~.` ~;:? ; ,` ; ,
<br />DATE OF ISSUANCE 2 O ~ O O { py ~ O • ;, .
<br />1 ! STANL,~Y S, GOdPER`°
<br />02/24/2010 ASSIar'Td, NT 1'L~ Tl~1~2''.~ •'
<br />DEPA~7M~~IF~~N~ ' „~
<br />LINCOLN, NEBRASKA HU~1,4N, SERVICES
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN $ERVICE$ 'ar: ' .. , ~ ~r
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<br />CERTIFICATE OF DEATH `~'r r~' - .~`{ , ~ ~; ~0 00469
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<br />1. DECEDENT'S•NAME (First, Middle, Last, Suffix) 2. SEX B_! DATE OF pEATHrMo., Day, Yr.)
<br />Levern Edward O'Brien Male February 18, 2010
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Oast Birthday b. UNpER 1 YEAR sc. UNpfeR 1 DAY e. DATE OF BIRTH (MO., Day, Yr.)
<br /> (Yrs.) MOS. PAYS HOURS MINS.
<br />Grand Island, Nebraska 66 January 15, 1944
<br />7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />507-62-2363 PIT ^ Inpatient OTHER ®Nursing Homa/LTC ^ Hosplca Facility
<br />84. FACILITY-NAME (Ii not Institution, give street and number) ^ ERlOutpatlent ^ Decedent's Home
<br />Western Hell County Good Samaritan Center ^ ooa ^ other (specify)
<br />8e. CITY OR TOWN OF DEA7N pncluda Zlp Code) 8d. COUNTY OF DEATH
<br />Wood River fi8883 Hall
<br />8a. RESIDENCESTATE 96. GOUNTY 9c. CITY OR TOWN
<br />Nebraska Buffalo Shelton
<br />9d. STREET AND NUMBER 9e. APT. NO. 8f. ZIP CODE 9y. INSIDE GITY LIMITS
<br />8781 S. Bluff Center Road 68876 ^ YES ®No
<br />10a. MARITAL STATUS AT TIME OF DEATH ®Married ^ Never Married 10b. NAME pF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />^ Married, but separated ^ Widowed ^ pivarced ^ Unknown CgnnlE Powers
<br />11. FATHER'S•NAME (First, Middle, Last, Suffix) 72, MOTWER'S-NAME (First, Middle, Malden Surname)
<br />William Roswell O'Brien Doris Grace Lange
<br />19. EVER IN U.S. ARMEp FORCES? Glve dates of service If Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO pECEDENT
<br />(Yes, No, yr unk.) No Connie O'Brien Wife
<br />75. METHOD OP DISPOSITION 18a. EMBALMER•SIGNATURE 16b. LICENSE NO. 18c. DATE (Mo., Pay, Yr.)
<br />® Burial ^ Donatlan Tracey Dietz
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<br />^ Removal ^ Other (Specify) 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> St. Mary's Cemetery Wood River Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADpRESS (Street, City or Town, State) 17b. Zip Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />AU W ee nstructions an exam les
<br />1e. PART I. Enter the chain of events. •dlaeases, Injuries, or Complicatlona-that directly caused the death. DO NOT gofer terminal events such as cardiac arrert, APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular flbrlllatlan without snowing the a[lalogy, 00 NOT ABBREVIATE. Enter only one cause on a lino. Add additional Ilnes If necessary.
<br />IMMEDIATE CAUSE: onset to death
<br />IMAA$OIATE CAUSE (Final a) METASTATIC HEPATOCELLULAR CANCER.. .,_ „ _, 4 YEARS
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<br />ditwaw or condhlon resuning "..."'"~
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<br />In death) pUE TO, OR AS A CONSEQUENCE OF:
<br />onset to death
<br />Seouentlally Itat conditions, 11 tl)
<br />any, Ieadinp to the puss Iltded
<br />on Ilne a.
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE c-
<br />Idlsedee OY Injury that Inltlated
<br />the events resulting In death) DUE 70, OR AS A CONSEQUENCE OF:
<br />onset to death
<br />LAST
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<br />18. PART IL OTHER SIGNIFICANT CONDITIONS•Condltions contrlbuting to the death but not resulting in the underlying cause given In PART I. 19. Wq5 MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />^ YES ®NO
<br />20. IF FEMALE; 21a. MANNER OF prsATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />^ Not pregnant wnhin past year ®Natural ^ Homicide ^ DnverlOparotor
<br />® NO
<br />^ Pregnant at time of death ^ AcCldem ^ pending Invastlgatlvn ^ Paswnger ^ YES
<br />^ Not pregnant, but prognant within 4Z days of death ^ Pedertnan 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />^ Sulclde ^ Could not be determined
<br />^ Not prognan6 but prognant 49 days to 1 year baforo death
<br />TO COMPLETE CAUSE OF DEATH?
<br />^ Other lSpaclfy)
<br />^ Unknown If prognant wkhin the part year ^ YE$ ^ NQ
<br />22a. DATE OF INJURY (Mo., Day, Yr,) 224. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, factory, office building, construction seta, etc. (Specify)
<br />22d. INJURY AT WORK? 226. DESCRIBE HOW INJURY OCCURREp
<br />^ YES [] NO
<br />22i. LOGATION OF INJURY • STREET ~ NUMBER, APT.NO. CnYITOWN STATE zlP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24i. AAT6 SIGNB>a•(Mp., pay, Yr.) gip. T1ME't7F fiP1tTH
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<br />~ Y 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF pEATH ~ ~
<br />24c. PRONOUNCED DEAD (MO., pay, Yr.) 24d. TIME PRONOUNCED DEAD
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<br />O 9d. To the bert of my knowledge
<br />death occurred at the time
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<br />B ~ and due to the cauasii) stated. (Signature and Tdle) E w 7 2so. On the bails of examinatlon andlor invsrtlpatlon, In my opinion deaM occurted al
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<br />Steven Husen, MD ~
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<br />28. Dlp TOBACCO USE CONTRIBUTE Tp THE pt2ATH? YBa. NAS ORGAN OR TISSUE DONATION BEEN CONSIDEREp? 284. WAS CONSENT GRANTED?
<br />^ YES ®NO ^ PRDBABLY ^ UNKNOWN ^ YES ®NO Not Applicable H 28a Is NO
<br />^ YES ^ NO
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<br />Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE 284. PATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 23, 2010
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