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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANNJ RVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NF#Rel SKA~L`P Ti( N ALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR Vf= R OS, , ` yy
<br />ANN,
<br />li l+
<br />DATE OF ISSUANCE , 'T+y'yh
<br />ST S GOOF R" , ,0
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<br />a
<br />7 A NT R
<br />JUL
<br />2 2010 D ~
<br />LINCOLN, NEBRASKA 201102561 M HUllptF INVWCE's
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPb
<br />AIT~
<br />f*FRTIFif_ATF Al: nFATH
<br />1. DECEDENT'S-NAME (First, Middle, Last, Suffix)
<br />2. SEX
<br />3. DATE OF DEATH(Mo., Day, Yr.),
<br />Melvin Dwight Chamberlin
<br />Male
<br />April 24, 2010
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE-Lest Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />S. DATE OF BIRTH (Mo., Day, Yr.)
<br />-
<br />(Yra:)
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />Mason City, Nebraska
<br />88
<br />March 4, 1922
<br />7. SOCIAL SECURITY NUMBER
<br />Be. PLACE OF DEATH
<br />508-12-8429
<br />li9SPJ7AL: ❑Inpatient 97tIE6 Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY-NAME (If not institution, give street and number)
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />Golden Living Center - Lakeview
<br />❑ ?X74 ❑ Other(Specify)
<br />- - -
<br />Bc. CITY OR TOWN OF DEATH (include Zip Code)
<br />OFDEATH
<br />COt1NTY
<br />Bd:
<br />Grand island 68801,
<br />Hall
<br />ga. RESIDENCE-STATE
<br />91. COUNTY
<br />9c. CITY OR TOWN.
<br />Nebraska
<br />Hall
<br />Grand Island
<br />gd. STREET AND NUMBER
<br />9e. APT. NO
<br />9f. ZIP CODE
<br />9g. INSIDE CITY LIMITS.
<br />1908 W is, St.
<br />68803
<br />Pt YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ NeverMarrled
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name.
<br />❑ Married, but separated S Widowed ❑ Divorced ❑ Unknown
<br />14. FATHER'S-NAME (First, Middle, Last, Suffix)
<br />12. MOTHER'S-NAME (First, Middle, Maiden Surname)
<br />Dwight Harrison Chamberlin
<br />Marie &lizabeth Funston
<br />18. EVER IN U.S. ARMED FORCES? Give dates of service if yes.
<br />14a. INFORMANT-NAME
<br />14b. RELATIONSHIP TO DECEDENT
<br />(Yes, no, orunk.) No
<br />Linda Wilson
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />,
<br />1Sa. EM R-SI RE
<br />NO.
<br />16b. LICENSE
<br />16c. DATE (Mo., Day, Yr. )
<br />Al Burial ❑Donation
<br />f'
<br />P1
<br />-
<br />/ 1Q
<br />April 28, 2010
<br />❑Cremation ❑Entombment
<br />t6d.CEMETERY. CREMATORY OR OTHER LOCATION CITYITOWN STATE
<br />❑Removal ❑Other(Specify)
<br />Mason City Cemetery, Mason City, Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Coda
<br />Kleine Funeral Home, 3213 W North Front St., Grand Island, NE 68803
<br />18. PART 1. Enter the chain of events-diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE ERVA11
<br />respiratory arrest, or ventficular fibriga9on wilhout'showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. I
<br />IMMEDIATE-.CAUSE: I oneettodeath
<br />I
<br />IMMEDIATE CAUSE(FInal (B) ~he G+~ ~ I rm"4-,~
<br />disaseorcondidonresutlktg DUETO,ORASAQONSEOUENCEOF: I onset to death
<br />In death)
<br />I
<br />Sequentially list conditions, III (b)
<br />any, ISWingtothecamRated DUE TO, OR ASACONS EOUENCEOF: I onset to death
<br />on linos. I
<br />Enter tho UNDERLYMG CAUSE
<br />(disease or Injury that Initiated (c)
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />tASr
<br />I
<br />(dt I
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />Q~
<br />❑ YES
<br />20. IF EMALE: j
<br />21e. AN ROF EATH
<br />210.1FTRANSPORTATIONINJURY
<br />21c.WASANAUTOPSY PERFORMED?
<br />❑ Not pregnant whhin pest year
<br />ral ❑ Homicide
<br />❑ Driver/Operator
<br />C3 YES Q-4
<br />❑ Pregnant at time of death
<br />El Accident❑ Pending Investigation
<br />❑Passenger UK
<br />-1
<br />/
<br />❑ Not pregnant but pregnant within 42 days of death
<br />Subida ❑ Could not be determined
<br />❑
<br />11
<br />❑ Pedestrian
<br />FINDINGSAVAl1ABLETO.. -
<br />21d. WERE AUTOPSY
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />I] Other (Specify)
<br />COMPLETE CAUSE OF DEATH?
<br />t
<br />o
<br />❑ Unknown If pregnant within the past year _
<br />-
<br />- - -
<br />l
<br />' ❑ YES _ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />M
<br />22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />22s. DESCRIBE HOW INJURY OCCURRED
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET a NUMBER, APT. NO. CITYITOWN STATE - ZIP CODE
<br />23a. DATE f D (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b.TIME OF DEATH m
<br />$
<br />L1F" j~
<br />y
<br />a 24c. PRONOUNCED DEAD (MO., Day,Yr.) 24d. TIME PRONOUNCED DEAD
<br />23b. DATE SIGNED (Mo., Day, Yc). 23c.TIME OF DEATH
<br />E ~
<br />y, ti:I 5 {q ITT W ` ITI
<br />$ °
<br />23d. To the best of my knowledge, death occurred at the time, date and place C 24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />and due to the cause( s) stated. (St tore and Title ) V Opp the 0me, date and place and due to the cause(s) stated. (Signature and Title) V
<br />QR Gi
<br />t
<br />CONTRIBUTE TO THE DEATH?
<br />USE
<br />25. DID TOBACCO
<br />DONATION BEEN CONSIDERED?
<br />260. HAS ORGAN OR TISSUE
<br />26b. WAS CONSENT GRANTED?
<br />O,
<br />EC
<br />❑ YES UYIVO ❑ PROBABLY ❑ UNKNOWN
<br />1
<br />&<01-
<br />O YES
<br />Not Applicable if 26a is NO ❑ YES
<br />27.N E, TITLE AND AD DRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />28a. REGISTRAR'S SIG TURE -
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />1- 2&!&
<br />Y 8 2010
<br />V
<br />HHS-61 11/03 (65061)
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