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STATE OF NEBRASKA � -
<br />WHEN THZS COPY GARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH°ANp, l(lfMQN S�RVICES, I7" CERTIFIES
<br />THE BEtOW TO BE A TRUE COPY OF THE DRIGINAL RECORD ON FILE WITH THE NEBRA$'11�4'Q�PARTM�N�' OF HEALTi�-1 ANQ
<br />HUMAN SERVICES, VITAL RE'CORDS OFFICE, WHICH IS TNE LEGAL DEPOSITORY FOR VIFA`t R6C0�4S,�-� ;;, " �
<br />DA7E OF ISSUANCE I�/��a�� � `� , - � .� .'
<br />ry - S7`���'S� �QC�'�.FjR �� � "> .>
<br />05I11 /2011 � O� i O(� C J 2 A�S�TANT 5T,�1-z� R�'�fSTRAR� ';
<br />� � ' DE�!?AY�'MEI�IT OF'.H�'ALTH A�KIi�. �; �, -.
<br />LIMCOLN, NEBRASKA H(IMAAI' S�'RYI�ES � � �
<br />� w �: �i 4 E a ,�` -
<br />STATE OF NEBRASKA • DEPARTMENT OF HEA4TH AND HUMAN SERVICES '' �, j'' : • " � � O'I SSS
<br />CERTIFfCATE OF DEATH -� ��� `"d.. � � .. �•_-
<br />DECEDENTS•NAME (FI[st, Mlddle, Last, Suftlu) 2. SDC ' `� 3• DATE OF DEATH (Mo., Day, Yr.)
<br />Paul Gene Crow Male April 21, 2011
<br />CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last 9lrthday b. UNDER 1 YEAR Se. UNDER 1 DAY 6. DATE OF BIFtTH (Mo., Day, Yr.)
<br />(Yre•) MOS. DAYS HOURS MINS.
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<br />Grand Island, Nebraska
<br />SOCIAL SECURITY NUMBER
<br />507-32-9120
<br />. FACill7'Y-NAME (M not irretitutlon, ghre street �
<br />Park Place-A Goiden Living Center
<br />, CITY OR TOWN OF DEATH (lnclude Zlp Code)
<br />Gra I sland 68803
<br />OF:
<br />� Drlvedoperator
<br />p ��
<br />� Pedeatrlan
<br />� Other (Specltyl
<br />� Hoapice Faclllty
<br />, RESIDENCE-STA7E 9b. COUNTY 9c. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />. STREET AND NUMBER 8e. APT. NO. 8L ZIP CODE 9g. INSIDE CITY LIMITS
<br />1203 East 6th Street 6884� ��S � Nfl
<br />a. MARITAL STATUS AT TIME OF DEATH � Martled ❑ Never Marrted 10b. NAME OF SPOUSE (Flrst, Middle, Last, Suftbc) fl wife, give maidan m,tme
<br />❑ n�mea, b� sa�xi�taa ❑ innaowaa ❑ ��►�aa ❑ u��ow� Carol Castor
<br />. FATHER'S-NAME (First, Mlddle, Last, Suffbc) 12. MOTHER'S•NAME (First, Mlddle, Malden Sumame)
<br />Richard W Crow Edna Robertson
<br />. EYER IN U.B. ARMED FORCES? Gfve dates of service R Y�. 14a. INFORMANT-NAME 74b. REWTIONSHIP TO DECEDENT
<br />(Yes, No, or Unk.) Yes 07/17l195&12/19/1958 Carol Crow W�e
<br />. METHOD OF QISPOSITION 18a. EMBA4MERSI(iNATURE 16b. LICENSE N0. 16c. DATE (Mo., Day, Yr.)
<br />� Burial ❑ Donatlon - ���gy Die1z 1328 April 25, 2011
<br />❑ Cremarion � EntombmeM �gd. CEMETERY, CREMATORY OR OTHER LOCATION CI7Y / TOWN STATE
<br />❑ Removal ❑ Other (Specity)
<br />WesUawn Memorlal Park Cemetery Grand Island Nebraska
<br />a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, Sfate) 17b. Zip Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />8. PART L F.iAer fhe c6aln M eveMe-dieeasee, InJuri�, m compticatlona-that dlrectly mused the death. DO NOT a�rterterminal eve� auch ae cardiac ar�at,
<br />reapiratory aneet, orveMrlcular tibriUedon wRhout ehowin8 the edology. DO NOT ABBREVIATE Ertter onlY o�re causa on a tltre. Atld addWonal Wree N necaseary.
<br />IMMEDIATE CAUSE:
<br />IMMm1ATE CAl1SE (Fhml a) Subdural Hematoma
<br />dieease ar candttlon rasutUng
<br />1° �� DUE 70, OR RS A CONSEQUF.IdCE OF:
<br />s�,m�� uee �o�a�n��, n b) Head Trauma
<br />anY� leading to the eau� Ils[ed
<br />on Ii�re a DUE
<br />F.�rterthe UNDERLYINQ CAUSE ��
<br />(dieease or inlury that inlBatatl
<br />the eve� resuidn9 In death) DUE
<br />� d)
<br />6. PART II.OTHER SIGNIFlCANT
<br />Atrial Flbriilatlon, Weakness
<br />� NM P�e9�M withln P� Y�'
<br />� a.ee� � ame ot aeau,
<br />� Not pregnart. 6ut pregaaM �rithtn 42 days aT deatt�
<br />� Not P�eB�k but pragnaM 4S daya to 1 year hefore deffih
<br />� Un�mown H preg�nt wHhin fhe pae! year
<br />75
<br />OSPIT � Inpatlern
<br />❑ ER/Outpatlent
<br />❑ DOA
<br />to the death 6ut rrot r�ulH� in
<br />ro
<br />� NaWrel � Homldde
<br />� Acdtle�k � Pending InveatiBatlon
<br />� Sulalde � CoWtl n0t be determined
<br />Za. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PL
<br />lJnknown Unknovm Home
<br />OTHER � Nursing Home/LTC
<br />� Deeetlerrt's Homs
<br />❑ Other lSPesffY)
<br />COUNTY OF DEATH
<br />Hall
<br />10, 1935
<br />APPROXIMATE INTERVAI
<br />o�met to death
<br />Days
<br />or�et to death
<br />orreet to death
<br />or�aet to death
<br />cause gtven In PART i. 78. WAS MEDICAL EXANOMER
<br />OR CORONER CONTACTEDT
<br />❑ ves p No
<br />TATION INJU 21c. WAS AN AUTOPSY PERFORMED?
<br />❑ t�s � NO
<br />21d. WERE AUTOPSY FlNDINGS AVAILA
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ ves ❑ No
<br />home, {erm, street, faetory, oftlee butldirtg,
<br />d. INJURYAT WORK4 22e. DESCWBE NOW INJURY OCCURSEO
<br />❑ ves � No Pa�ent had history of many falts. Many were unwitnessed. This injury was unknown.
<br />L LOCATION OF INJURY - STREEI' 8 NUMBER, APT.PIO. CITY/TOWN STATE ZIP CODE
<br />Jnknown, Unknovm Unknown
<br />23a. DATE OF DEATH �Mo., Day, Yr.) _ 24a, RAiE SiGNE-L-{Mo.,-�sy Yr.)-- 246. TIME-Qf DEArH =
<br />April 21, 2011 .� �
<br />� 23b. DATE SIGNED (Mo, Day, Yr.) 23c. TIME OF DEATH ���� 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />�Z Ma 11,2011 07:57AM Edao
<br />p To fhe bee! of my knowled8e, death occu[retl at the tlma, date and Rle� $�� 24e. On Ure baele Mmreminetlon and/or Invaeti8adon, in my opinlon deatU occurted et
<br />ma
<br />antl due to the eeuse(el8lated. (Stg�mture end Tkie) �& p the 8me. date aml P�eae and due to the ceuse(e) eteted• (Signature e� TIUe)
<br />t7
<br />$ Travis S. Hageman, MD ~ g o
<br />YES I NO I PROBABI.Y � UNKNO
<br />Travis S. Hageman, MD, 72 North
<br />�. REGISTRAR'S SIGNATURE /��.
<br />WN I ❑ YES � NO � Not Appllcabie H 26a Is NO ❑ YES ❑ NO
<br />I ASS T RO t �3 PH SI� R A El� (Type or PNrR
<br />Avenue, Grand Island, Nebraska, 68803
<br />28b. DATE FlLED BY REGISTRAR (Mo.,
<br />May 11, 2011
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