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STATE OF NEBRASKA i"
<br />� WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL`�� XIIV�D� �ItJMAN SERVICES, IT CERTIFIES
<br />THE 'BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBfjA�SJf.�1����F�A��FIVI�NT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORI' fdITiAL RECORcDS. �
<br />� � �;��� �,r� � i , ,, ,
<br />DATE OF ISSUANCE " ��� � r
<br />� 012 0 9 �12 � ' �= L ; STANLEY S. COOPER �� � � ��, '
<br />09/13/2012 ,. ,� :AS�i��vT R��IS�F'RAR '
<br />; � 'DE�AR7"MC�IV7?�YHEAi�i���ND ,
<br />LINCOLN, NESRASKA ��r �� 'I�UMAN SERV�CES � ,� ,.,�` ;;�
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SEBVI���� c'y �' � 1r ���•
<br />' CERTIFICATE OF DEATH ° � `���' '���'� ,;.� �" 12 03319
<br />�. ..... .-� �
<br />1. DECEDEI3TS•NAME (Flret, Mlddle, Laet, SuHbc) 2. �S�X, � ��� � 3.DATE OF DEATH (Mo., Day, Yr.)
<br />�,�, q. '
<br />David 'E Gerlach Male �•`:.' 4�� ' 9, 2012
<br />4. CITY AND,$TATE OR TERRITORY, OR FOREION COUNTRY OF BIRTH Sa. AGE • Last 8lrthday b. UNDER 1 YEAR 5c. UNDER 7 OAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />lY�•) MOS. DAYS HOURS MINS.
<br />Broken Bow, Nebraska 63 May 5, 1949
<br />7. &OCIAL S CURITY NUMBER 8a. PLACE OF DEATH
<br />507-66-1000 �ay � im,aeeM OTHER ❑ Nursing Home/LTC � Hospice Faclltty
<br />Btl. FACILIIY-NAME (If not InsUbrtlon, give street ami number) � ER/Outpatlent ❑ Decedent's Home
<br />�
<br />� Saint Francis Medical Center ❑ ooA ❑ ane� �specrcy�
<br />c�
<br />� Bc. CIT'Y OR TOWN OF DEATH pnclude Zlp Code) 8d. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 9a. RESIDENCESTATE 8b. COUNTY 8c. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />LL 9d. STREET AND NUMBER . APT. NO. 8f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />1108 E. Oklahoma Ave 68801 � ves ❑ No
<br />$ 10a. MARRAL STATUS AT TIME OF DEATH � Marrled ❑ Never Martied 10b. NAME OF SPOUSE (FIrsQ Mlddle, Laet, Suffbc) ftwife, give malden �me
<br />� ❑ n�m�a but separeted ❑ Widowed ❑ oworeaa p u��ow� patric(a Diessner
<br />� 11. FATHER'S•NAME (First, Middle, Last, SuHi�c) 12. MOTHER'S-NAME (Flrst, Middle, Malden Sumama)
<br />« Donald Gerlach Marva Best
<br />m
<br />°' 73. EVER IN U.3. ARMED FORCES? t3ive dates of saMce H Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />g �r«, No, or unic.) Yes 04/17/196&04/16/1970 Patricia Gerlach Spouse
<br />,� 1b, METHOD OF DISPOSITION 18a. EMBALMER�.SIGNATURE 16b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F ❑ Burlal ❑ DonaUoa
<br />Not Embalmed September 10, 2012
<br />� CremaUon ❑ Errtombment �gd. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Remov�i ❑ Other (SpecfFy) �ntral Nebraska Crema�on Servfces Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AfdD MAIUNG ADDRE53 (Street, City or Town, State) 17b. Zip Code
<br />All Faith� Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See instructions and exam les
<br />7& PART 1. Fste ure enem or everrts-�diseaeee Iryurles, or compUcatlona-that tllrectly caused the Aeath. DO NOT e�rter termUmt eveMe sueh as cardlac arteat, p APPROXIMATE INTERVAL
<br />�espUaMry.�artest, or veMrlcuiar fibrllladon without showing the etlalogy. DO NOT ABBREVIATE Errter anty o�re cauae on a 16re. Add addWOnal llnea iT neceseary.
<br />esp
<br />, IMMEDIATE CAUSE: ; on.98t to death
<br />meaeeowre cqusE �mai a) Cardiac Arrest 6 Hours
<br />dlsease or wnditlon reauiting ;
<br />� d � ) , DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />Sequentlaly ll8t contlltlone, tt b) Hyperkalemia : Hours
<br />any, leading to'4he cauae Ileted
<br />on u�re a ' DUE TO, OR /6S A CONSEQUENCE OF: : ormet to death
<br />EntertheUNDERLYINOCAUSE �)Acute Renal Failure � E Hours
<br />(d�9ease or In]Yry that Inidated -
<br />��"� ��" �" �'� DUE TO, OR AS A CONSEpUENCE OF: : onset to death
<br />� d� i
<br />18. PART II. q4HER SIGNIFICANT CONDITIONS-CorMWons conM6uting M the death but not resulU� in the umleNying cause ghen In PART 1. 18. WAS MEDICAL EXAMINER
<br />Ischemic Cardiomyopathy, Pulmonary Hypertension, COPD, Hypertension, OSA, Diabetes Mellitus OR CORONER CONTACTED?
<br />� ❑ res p No
<br />� 0. IF FEMAL : 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />F Q Not pregnaM within paet year � Natural � HomidAe � DrtvedOperetor
<br />u��l [] are �C e�re ora�n � a�aa.M � Pending Inveati9atlon ❑�"e� 0 res � No
<br />� Not pregnant, but pregnam wwiin s2 deye ot death � Peuestrian 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />'� Q NoS pra8�� bu! pregnaM 43 daye M 1 year before d�th � 8 ��� ❑ COUtd nM De uemrmlired ❑ � r (S�c�) TO COMPLETE CAUSE OF DEATH7
<br />� ❑ ves ❑ No
<br />m ❑ un�mown iB p�e¢neM wkliln ure v� r�
<br />n ' 22a. DATE O,INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY�At homa, tarm, street, Tactary, ofFice butiding, cor�truetion aite, etc. (Sp�ity)
<br />E
<br />s
<br />� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />�"' � YES C ❑ NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYITOWN STATE LP CODE
<br />23a. DATE OF DEATH (Mo„ Day, Yr.) ` 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />�' September 9, 2012 S � �
<br />�� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ��' k 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� Z e tember 10, 2012 09:32 PM a<�
<br />� � Sd. To tlre bes2 of my Imowledge, death oewrted at the tlme, de[e and plaee $��� 24e. On tite basls ot eraminedon end/or Investlgadon, In my opinlon deatii oaurted et
<br />$ �nd due M the eause(s) ste[ed. (SlgnaWre antl Title) 8� $ the 8me, date and place and tlue to the eause(s) stated. (318neture antl Tltle)
<br />~� Jay C. Anderson, MD ~ g s
<br />25. pID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED7
<br />� YES �❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Appllcable ff 28a Ia NO ❑ YES ❑ NO
<br />27. E, TITLE AND AD TIFIER (Type or Prirrt
<br />Jay C. Mderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'3 SIGNATURE �- � 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />September 11, 2012
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