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<br />STATE OF NEBRASKA --._:- �2 O 12 O 4���.
<br />•, "�..`
<br />WHEN THIS CQPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH �4�D F11�#'I�I�S,��2VICES,IT CERTIFIES
<br />THE BELOW TO BE A TRtIE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASK,�' D,E�XI�&�l�l�'NT�'�l-�EALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE WHICH IS THE LEGAL DEPOSITORY FOR VFT�� 1������• •. :�
<br />.. �
<br />DATEOFISSUANCE EXHIBIT ��� `.���� �
<br />'. ._ �, .
<br />ST',4IV��' S: ,�QqPER " `„ ,..''
<br />04/17/2012 � "A" ASSI�TAI1IT �A� �G�S_TRAR!'_' ;; , �
<br />DEP�I�'TNjE�I�QF'��'ALTH AN� � .�' - �
<br />LINCOLN, NEBRASKA HUl�1,�4�' ,R��CES + c , : ;"',' �
<br />STATEOFNEBRASKA-DEPARTMENTOF EALTHANDHUMANSERVEC��,$,�.r f . tiY{ f� . �Z O'IS24 ;'
<br />CERTIFICATE OF DEATH ``!� `�F ' " " . � Fi`' � ��
<br />1. dECEDENT&NAME (Firat, Mlddle, Last, Sufflrz) 2. SEX �_, �. �` DATE dF'DEqTH (Mo:, Day, Yr.)
<br />Donald Duane Mead Male `' `Ap�il"8; 20'12
<br />4. GITY AND STATE OR TERRITORY, OR FOREIGN COIINTRY OF BIRTH Sa. AGE • Last Birthtiay b. UNDER 1 YEAR Bc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y�•) MOS. DAYS HOURS MIN3. � ' �
<br />Wo� River, Nebraska 77 January 5, 1935
<br />7. SOCiAL SECURITY NUMBER 8a. PLACE OF DEATH �
<br />806-40-1462 OS�I PRAL � Inpatleqt OTHER ❑ Nursi� Home/LTC � Hospice Faclllty
<br />86. FACILITY-NAME (Ii rtot IretituUon, ghre atreet and number) � ERIOuq�aUeM ❑ Decede�'s Home .
<br />�
<br />� Good Samaritan Health Systems ❑ ooa ❑ o�ner �spectty�
<br />� 8c. CITY OR TOWN OF DEATH pnclude Zlp Code� � 8d. COUNTY OF DEATH
<br />c Keamey 68848 BufFalo
<br />� �. RESIDENCESTATE 8b. COUNTY 8e. CITY OR TOWN
<br />Nebraska Hall Wood River
<br />LL Sd. STREET AND NUMBER e. APT. NO. 8L ZIP CODE 9g. INSIDE CITY LIN0T9
<br />�, 512 Lilly Street 68883 � v�s ❑ No
<br />� 10a. MARITAL STATUS AT TIME OF DEATH � Marrled � Never Marrled 10b. NAME OF SPOUSE (Flrst, Middle, Last, SuBix) it wNe, give maiden name
<br />€ b nnarr�ea but eaparated ❑ vndowad ❑ n�vorcea ❑ unknow� Mariene Dibbem
<br />� 11.'FATHER'S-NAME (First, Middle, Last, SufNx) 12. MOTHER'S•NAME (Firat, Middie, Maiden Surrmme)
<br />Delbert G Mead Edna A Wiese
<br />E 13.�EVER IN U.S. ARMED FORCESI Gfve dates Maervlee If Yea. 74a. INFORNUWT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ es, No, ar unk.) No Marlene Mead Spouse
<br />,� 1S. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 18c. DATE (Mo, Day, Yr.)
<br />F �] BuHai ❑ DormUon Derek Apfel 1240 April 13, 2012
<br />(� Crert�Uon Q ErrtombmeM 18d. CEN�TERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />[] Remorai ❑ Otlter (SpecHy) �ntral Nebraska CremaUon Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND NIAILING ADDRE83 (SVeet, City or Town, State) 17b. 2ip Code
<br />�lpfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See Instructions and exam les
<br />7& PART I. EMer the ehain M eveMe-4lseasea, InJuriea, or comptieatla�thaS tllreetly eauaed the death. DO NOT eMer lerminel eveMs suah ae ceNiec arteet, ; APPRO70MATE INTERYAL
<br />� resplratory artest, or ve�micuiar Iibrlllatlon wfthout ahowing the etlotogy. DO NOT ABBREVIATE. Errtaz onty o�re wuse on a p�re. Add eddltlonai �irea B neceaeary.
<br />IMMEDIATE CAUSE: ; onset to death
<br />mep�ou►re cause �,�i a) Respiratory Failure ; Immediate
<br />di8eaee or condttlon resultlng
<br />� d � ) DUE TO, OR AS A CONSEQUENCE OF: ; ormet to death
<br />8equeMlaDy Iist condlUO�m, H b) pneumonia E 6 Weeks
<br />anY. IeaUing to tlre muse IleteO �
<br />on mre a. DUH TO, OR AS A CONSEQUENCE OF: 7 onset to death
<br />Emerme uwo�nNO cause �) �Pira�on : 6 Weeks
<br />(elsaase or In1�Y Uut Initlated
<br />are eveMe resunme M death) DUE TO, OR AS A CONSEQUENCE OF: C anset to death
<br />� d)
<br />18. PART II.OTHER SIGNIFlCANT CONDITIONS�CorMklons contrlbuUng to the death but not resultl� In the urtderiying cause gtren In PART I. 18. W/!S MEDICAL D(AMINER
<br />Coronary Artery Disease, Chronic Obstructive Pulmonary Disease OR CORONER CONTACTED?
<br />� ❑ ves � No
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. W/64 AN AUTOPSY PERFORMED?
<br />� � Not PraBna�Rwfthin pasty�r � Natural � HomlWde � DriverlOPBT�o► � YES � NO
<br />W Pregnairt eS time o( deatlt Pes6eeBei
<br />V � � AcddeM � Pending Investigatlon
<br />t� [] Nat pregnam, 6ut pregnant wRhin 42 daye ot death ��Gde Could not be determ�ned � Pedestr�a" 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />S�' � N � � � P1e �� m ��� � ❑ ❑ ��� � TO COd1PLETE CAUSE OF DEATH?
<br />� ❑ Unimown fl pre8nant wffhin the P� Y�
<br />❑ ves ❑ No
<br />E 22a. DATE OF MJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY At home, farm, etreet, factory, oftice bWlding, co�tructloe a(te, etc. (Speclfy)
<br />$
<br />.� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />� April 8, 2012 � � �
<br />�� 23b. DATE SI(3NED (Mo., Day, Yr.) 23c. TIME OF DEATH �� k r 24c. PRONOUNCED DEAD (Mo, Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� � Z A ril 8, 2012 08:25 PM �< o
<br />$� � 3d. To the beat o►my b�owlad8e, death ouurted et Ne dme, date and P��e $�� 24e. On the besis M exeminatlon anNor Imeatigadon. In my oPlnion death occurreA et
<br />+� and due W fhe cause�e) stated. (319�eMe and TWe) � � the tlme, date and place m�d due to the tause�e) stated. (Slgnature and Tltia)
<br />~� Michael C. Bibler, DO ~ o s
<br />25. DID TOBACCp USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT ORANTED7
<br />� YES ❑ NO ❑ PROBABLY ❑ UNIWOWN � YES ❑ NO NotApplicable H28a Ia NO ❑ YES � NO
<br />27. E, T F ER I R(PHYS C , S T, O ER P U A O El� (Type or Pdnt)
<br />Michael C. Bibler, DO, 3219 Central Avenue, Keamey, Nebraska, 68847
<br />28a: REGISTRAR'S SIGNATURE � 28b. DATB FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />April 16, 2012
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