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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH.AND+MUVAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAKApvi OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FDA yI AL RECOt DS. i DATE OF ISSUANCE STANLEY S. COOPER 201305369 AND 17ERAR ENT OF HEALTH AND LINCOLN, NEBRASKA f. UMAN SERVICES • SEP 012011 STATE OF NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S ,` f; 1," 2W 227 - 'CDTfrfrn nG fl ATU Insta 2013 - 9.18 3 1. DECEDENTS -NAME (First, Middle. Last, Suffix) Jerry Quaring 2. SEX +'. ; Male '3. DATE OF DFA'TH (MO ,bay,Yr.) August "14; 20 11 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE -Last Birthday (Yrs.) • 67 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) February 15, 1944 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -62 -1155 8a. PLACE OF DEATH HOSPITAL: IXI Inpatient QIyE& ❑ Nursing Home/LTC ❑ Hospice Facility - ❑ ER/Outpatient ❑ Decedent's Home ❑DOA ❑otner(speoify) lb. FACILITY -NAME (If not Institution, give street and number) Good Samaritan Health Systems 8c. CITY OR TOWN OF DEATH (Include Zip Code) - Keamey 68848 8d. COUNTY OF DEATH Buffalo 1 iNn4 :AO PellPaJp9 a)dwo3 a 3 of Ll3WLLL1B3 :Aq pa ;aidwo3 as o} l / 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Buffalo 9c. CITY OR TOWN Shelton 9d. STREET AND NUMBER 19995 Sioux Road 9e. APT. NO. 9f. ZIP CODE 68876 9g. INSIDE CITY UMITS ❑ Yes ® No 10a. MARITAL STATUS. AT TIME OF DEATH RI Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) I wife, give maiden name. Frances VanVleet 11. FATHER'S -NAME (First, Middle, Last, Suffix) Everett Arthur Quarnq 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Erma Moss 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 06/22/1966- 03/25/1968 14a. INFORMANT -NAME rances Quaring 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr.) August 13, 2011 15. METHOD OF DISPOSITION Wanda! ❑Donatlon ❑Cremation ❑Entombment ❑Removal ❑Othsr(Speeiry) 16a. EMBALMER -SIG R ' /` / /^ ', �t.�/fsl 16b. LICENSE NO. 910 e G led. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE Riverside Cemetery Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Rasmussen Mortuary, 311 Grand Avenue, Ravenna, Nebraska 17b. Zip Code 68869 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the Chain of wenta - diseases, Injuries, or complication- that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL raaplratory arrow, or ventricular fibriliativn without ehowina '•he etiology. DO NOT ABBREVIATE. Enter eniy one r-ause on a lira. Add additional lines if necessary. IMMEDIATE CAUSE: onset to death o d a) CQI�U.i`o pu(.mowLry 19-rY.esi- i oncefra ( C-- disease or condition ( in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list Conditions, If b) d any, leading to the cause listed A-50701-ton on line a. - ' DUE TO, OR AS A CONSEQUENCE OF: onset to death rV/ Enter the UNDERLYING CAUSE c) T 01 4 S (disease or Injury that initiated onset to death the events resulting in death) DUE TO. OR AS A CONSEQUENCE OF: LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ❑ NO 20. IF FEMALE: ❑Not pregnant within past year 0 Pregnant at time of death ['Not pregnant, but pregnant within 42 days of death ❑Not pregnant, but pregnant 43 days to 1 year before death ['Unknown if pregnant within the past year 219AANNER OF DEATH EgNatural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? DYES /N 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? DYES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction Site, etc. (Specify) 22d. INJURY AT WORK? DYES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 221. LOCATION OF INJURY - STREET 4I. NUMBER, APT. NO. %WINriGWH STATE ZIP CODE K a W ts K m o o , Q xi p O W �� 23a. DATE OF DEATH (Mo., Day, Yr.) August 10, 2011 Z r a v z 2 > 0 r cc4 o o W z 2Z= = O g V QU 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH re 23b. DATE SIGNED (Mo., Day, Yr.) August 25 2011 23c. TIME OF DEATH 08:50 a m 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD m 23d. To the . est knowled. -, . eath occ • rred at the time, date and place and du to us s) - ated. (Signatu �: a . •) ♦ � �� 24e. On the basis of examination at the time, date and place and/or investigation, in my opinion death occurred and due to the cause(s) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES %NO 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES - NO 25. DID TOBACCO USE CONTRIBUTE TO l - • + ) DYES 14 NO ❑ PROBABLY ❑ UNKNOWN 27. NAME TIT AND ADDR OF RTIFIER , YSICIAN, ' YSICIAN ASSLSTA R'S NT, OR E H( NqA CQ�UNTY ATTORNEY) (Type or Print) I J 4r I i�S E. 31st St. , {tearney, ICE 68847 II"--) P 28a. REGISTRAR'S SIGNATURE ` 4 / d 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) AUG s 0 2011 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH.AND+MUVAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAKApvi OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FDA yI AL RECOt DS. i DATE OF ISSUANCE STANLEY S. COOPER 201305369 AND 17ERAR ENT OF HEALTH AND LINCOLN, NEBRASKA f. UMAN SERVICES • SEP 012011 STATE OF NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S ,` f; 1," 2W 227 - 'CDTfrfrn nG fl ATU Insta 2013 - 9.18 3