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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES TH
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<br />E RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND FfUMAN:S€RVICES, I7" CERTIFIES
<br />THE BELOW 70 BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR.4S�1�'��'F� L2F�f�i�i9LTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE lEGAL DEPOSITORY FQR�TA,�:/�.�tY��,� ��� -
<br />DATE OF ISSUANCE ���� ���� "
<br />SEP 24 2o0s 20�,.�07252
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT'S•NAME.. (First, Mlddle Leat, Suttfx)
<br />70SEPH ene CROW
<br />4. CITY AND STATE OR TERRITORY, OR FOREIpN COUNTRY OF BIRTH 5s. A(iE-Leat Birthday 6b. UNDEfl 7 YEAR
<br />GRAND ISLAND, NE t��e•>7g MOS. DAYS
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<br />;�7'�N�EY S. �d.�'Rr, f . ;�
<br />.-XI 5�7�7A�'$IATE REGI'�TR�4R�';
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<br />FINANGFOKIt]�kIPP� Y . ; _,_ -
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<br />'.. SEX 3. DATE OF DEATH (Ma., Day, Yr.}
<br />MALE 9-17-2008 �
<br />5c. UNDER 7 DAY ' 8. DATE OF BIRTH (MO., Yr.j
<br />Houas MINS. ],2 _24-1929
<br />7. SOCIAL SECURITY NUMBER Ba, pLpCE OF OEATH
<br />506-28-2584 NOSPITAL ❑ ��auem � C,�NuraMgHome/LTC ❑�keFacuu
<br />Bb. FACILITY-NAME � pt noi Inatitutlon, give street and numberj
<br />VA MEDICAL CENTER ❑ e�outpauent ❑ oecedeneaHome
<br />2201 N BROADWELL ❑ � ❑ ouier(svectry>
<br />Sc. CITY OR TOWN OF DEATH pnclude Zip Code) Bd. COUNTY OF DEATH
<br />GRAND ISLAND HALL
<br />9aRESIDENCESTATE 9b.00UNTY 9c.CiTYORTOWN � � .
<br />NE HAI,L GRAND ISI;AND
<br />9d.31'REETANDNUMBER Be.APT.NO Bf.ZIPCODE Bg.IN31DECITYLIMITS
<br />108 Lakeview Circle �12 68803 �] ves a No
<br />t0a. MARITAL STATUS ATTIME OF DEATH 0 Married ❑ Nerer Marrfed tOb. NAMEOF SPOUSE (Firat, Mtddle. Leat, Suflix) If wife, gfve malden nema.
<br />0 Marrletl, but aeperetetl O Widowed �] Dhrorcad O Unknoxm
<br />11. FATHER'S•NAME (First, Midd�e, � � Last, Suf11x) 72. MOTHER'S-NAME (Firat, Mlddle, Malden Surname)
<br />RICHARD W. CROW EDNA MAY ROBERTSQN
<br />13 .EVERINU.9.ARMEDFORCES7�Ivede[eaofaervlceByea. 74e.INFORMANTNAME � 14b.RELATION3HIPTODECEDENT
<br />t�a ,no,orunk.}� � �.12-1952-01-21 1954 Richard Crow Brother
<br />15. METHOD OF DISPQSITION 18e. EM R-SIO R 16b. LICEN3E N0. 18c. DATE (Mo.. Day, Yr. )
<br />❑� v�e��� September Z0, 200
<br />C�Crematlon ❑Fstombmenl �ed•CEMEI'ERY,CREM T RYOROTHERLOCATION CITY/TOWN STATE
<br />❑ Removal Q OIAar (Spec(ty)
<br />Westlawn Memorial Park Crematory, Grand Island, NE
<br />17a FUNERAL HOME NAME AND MAILINO ADORES9 (Sheet, CttyorTOwn, State) ' 17b. Zip Code
<br />Apfel Funeral Home, 1123 West Secoad, Grand Island, NE. 68801
<br />1& PART I. Enter the �hain ot events-diaeases, inJuriea, or complicadons-that directly caused the deflth. DO NOT enter terminel events auch as cardlec etrest, APPROXIMATE IMERVAL
<br />I
<br />reapiretory arrest, or venMcular fibriliatlon wtthout ahowing ffie eUoiogy. DO NOTABBREVIATE. Enter only ona cause on e Iine. Add additlonal Ilnes R necesaery. �
<br />ItdMEDIATE CAUSE � onaet to death
<br />I
<br />�� RESPIRATORY FAILURE '
<br />@mF1ED1ATECAUSE(Flnai �
<br />�O DUETO,ORASACQNSEQUENCEOF: I onaettodeath
<br />In death)
<br />s�v„emi�iyu��,,,dx�,�,n ro� CARCINOMA OF THE LTJNG W IT13 RADIA '
<br />�'�� DUETO,ORASACONSE�UENCEOF: �
<br />on If�rea I onset W death
<br />�e,a�ur��xwocaus� PNEDMONIAS �
<br />(msea�emtMurytnm�nteatea �°1 C$RONIC OBSTRIICTIVE. PUZMO�RY DISEASE i
<br />�� DUETO,ORASACONSEQUENCEOF: I onsettodeaffi
<br />lJ�l'
<br />c� CORONARY ARTERY DISEASE AND ATRIAL FIBRILLATION '
<br />18. PART II.OTHER SIONfFICANT CONDITION$•Condi�orq contr@uting W�the deaN but not resulUrig in the urMerlying cauae given tn PART I. 18. WAS MED�CAL IXAMINER
<br />OR CORONER
<br />0 YES t9 NO
<br />20.IFFEMALE:, 21aMANNEROFDEATH 21b.IFTRANSPORTqTIONINJURY 27c.WASANAUTOPSYPERFORMED7
<br />❑ Not pregnant wlthin pset year � Neturai ❑ Homicide 0 OrlvedOperator
<br />❑ Pregnent at time of death ❑ Accidant0 Pe�ing Inveatlgatlon
<br />❑Pesaengar ❑ YES �l NO
<br />❑ Notpregnant,butpregnflntwfthfn42dayso(death � 21dWEFlEAUTOPSYFINDIN�SAVAM8LET0
<br />❑ smcwe ❑ CoWd not ba detertnirted p�,er (sa�ty�
<br />� Notpregnant,bNprep�nt43dayetotyearbeforedeath - . COhiPLEI'ECAU3EOFDEATH?
<br />❑ UnknownRpregnantwithinthepastyear O YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF �NJURY-At homa, farm, street, tactory, oBlca building, conaWctlon sfte, etc. (Spacity)
<br />+n -- _ _-
<br />22d.INJURYATWORKT 22e. DESCRIBE HOW INJURY OCCURRED
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY • STREEI' & NUMBER, AP7: N0. CITY/fOyyN SpQE ZIPCODE
<br />23a. DATE OF DEATH (Ma, Day, Yr.) 24a DATE S��NED (Mo., Day, Ycj 24b.TIME OF DEATH
<br />.�� SEPTE�ER 17, 2008 ,�� � m
<br />�� y 23b. DATE SI�NED (Mo., Day,Yc) 23o.TIME OF DEATH ��� 24c, pRONOUNCED DEAD (Ma, Day,Yr.) 24d.TpNEPRONOUNCm DEAD
<br />E�o SEPTII�ER 17 2008 9: 24 � a a � m
<br />8� 23d.To tha beat of my Immviedge, death occurred at the iime, date and place ���� 24e. On the basis of exeminetton and/or InvesUgeGon, in my opinion death occuned et
<br />F due to the cause(s) etatad. (Signature and Title )♦ � p 8 the time, data and piace antl tlue to the cauea(s) stated. (Signeture end Tttle )♦
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<br />25.DIDTOBA OUSECONTRIBUTETOTHEDEATH? 26a.HA30R6ANORT7SSUEDONATI0N8EENCONSIDEREDT ,28b.WASCONSENTGRANTEDI
<br />�YES ❑�NO ❑PROBABLY ❑UNKNOWN ❑YES . �]�NO NotAppllceb1e7f26a1aN0 �❑YES ❑NO
<br />27.NAME,TITLEANDADDRESSOFCERTIFIER (PHYSICIAN,CORONER'SPHYSICWNORCOUNIYATTOHNEI� (rypeorPdnt)
<br />Heidi Beckett, M.D. VAMC G:rand Island 2201 N Broadwell Grand Island NE 68803
<br />28aRE013TRAR'S31flNATURE �. ' � � - � 28b.DATEFIL�aY,QE��R (�1y,��,Yr.)
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