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STATE OF NEBRASKA
<br /> 201306908
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES,IT CtK 1I Ht5
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL��R��EC/O�RDS.
<br /> DATE OF ISSUANCE ��� r!hj 4 L
<br /> JUN 2 0 Z013 ASSISTANT STATE REGISTRAR
<br /> DEPARTMENT OF HEALTH AND
<br /> LINCOLN,NEBRASKA HUMAN SERVICES
<br /> Amended June 20, 2013 STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br /> Amended June 18, 2013 CERTIFICATE OF DEATH 13 2 4 3 3 3
<br /> 1.DECEDENTS-NAME(First, Middle, Lae% Suffix) 2.SEX - 3.DATE OF DEATH(MO.,Day,Yr.)
<br /> Gary William Monter Male May 19,2013
<br /> 4.CITY AND STATE OR TERRITORY,OR FOREIGN COUNTRY OF BIRTH Ea.AGE-Last Birthday 5b.UNDER 1 YEAR Sc.UNDER 1 DAY 8.DATE OF BIRTH(Mo.,Day,Yr.)
<br /> (Yre.) MOS. DAYS HOURS MINE.
<br /> McCook,Nebraska 53 August 24,1959 .
<br /> 7.SOCIAL SECURITY NUMBER 8a.PLACE OF DEATH
<br /> o 5 ot, 500 30l 508-88-3446 ` HOSPITAL;u Inpatient OTHER(❑Nursing Home/LTC ❑Hospice Facility
<br /> V Bb.FACILITY-NAME(H not Institution,give street and number) ®ER/Outpatient ❑Decedent's Home
<br /> w Memorial Hospital-Seward ❑boa ❑ome(speeirY)
<br /> 0
<br /> -I So.CITY OR TOWN OF DEATH(Include ZIP Code) ad.COUNTY OF DEATH
<br /> g Seward,) 68434 Seward 11
<br /> = 9a.RESIDENCE-STATE 9b.COUNTY 9c.CITY OR TOWN
<br /> U.
<br /> ,, Nebraska I Hall Cairo
<br /> 5
<br /> 98.STREET AND NUMBER 9e.APT.NO. 9f.ZIP CODE 9g.INSIDE CITY LIMITS
<br /> B 304 Hillside Dr 68824 ❑Yes ®No
<br /> I 10a.MARITAL STATUS AT'TIME OF DEATH®Married ❑Never Melded 1Ob.NAME OF SPOUSE(First,Middle, Last, Suffix)if wife,give Walden name.
<br /> ❑Married,but separated❑Widowed ❑Divorced ❑unknown Jaye t$0Bk0B.
<br /> 11.FATHER'S-NAME (First, Middle, Last, Suffix) 12.MOTHER'S-NAME(First, Middle, Maiden Surname)
<br /> 0'
<br /> William Monter Mona Cross
<br /> m 13.EVER IN U.S.ARMED FORCES?Give dates of service If Yee. 14a.INFORMANT-NAME 14b.RELATIONSHIP TO DECEDENT
<br /> F
<br /> (Yea,No,or um)No Jaye Monter Spouse
<br /> •
<br /> 18.METHOD OF DISPOSITION 1 MBALMER-SIGNATURE 1 ieb.LICENSE NO. 18e.DATE IMo.,Day,Yr.)
<br /> Osumi ❑DOrxtian ! mac..- /.,(v,� I [3 j 05/27/2013
<br /> ®nmmallon ❑F,eomement
<br /> ❑RemevM ❑Oate4ap0000I 16:d.�C METERY,CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br /> Westlawn Memorial Park Crematory Grand Island Nebraska
<br /> 17a.FUNERAL HOME NAME AND MAILING ADDRESS(Street,City or Town,State) 176.2Ip Code
<br /> Livingston-Sondermann Funeral Home,601 N.Webb Road,Grand Island,Nebraska 68803
<br /> CAUSE OF DEATH(See instructions and examples)
<br /> le.PART I.Enter Me 08110 of eVe,,,-aeon,...01.01..,or complintdone-tM directly mood the dots.DO NOT enter ten inalWSme eats at urdlao attest APPROXIMATE INTERVAL
<br /> ,aspiratory erne!,or v.Mdrolarfbdllenon weheul stowing Ilia etiology.DO NCO A99REVIATO.Enter only one uusa an a line.Add additional Ilnee a necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE(Final Coronary disease or condition resulting a) nay Thrombosis and Acute Myocardial Infarction Hours
<br /> In death)
<br /> DUE TO,OR AS A CONSEQUENCE OF: onset to death
<br /> _ Sequentially list conditions,if b) Severe Arteriosclerotic Heart Disease Years
<br /> any,toadied to the ammo listed
<br /> on,inns. DUE TO,OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERLYING CAUSE 01
<br /> -^ (disease or injury that I r a',.
<br /> the events restating In death) DUE TO,OR AS A CONSEQUENCE OF: onset to death
<br /> LAST
<br /> d)
<br /> 18.PART IL OTHER SIGNIFICANT CONDITIONS.Condldons contributing to the death but not resulting in the underlying cause given In PART L 19.WAS MEDICAL EXAMINER
<br /> OO}FFR��CORONER CONTACTED?
<br /> `C.1 YES ❑NO
<br /> re
<br /> D i 20.IF FEMALE: }2�1.$ar.MANNER OF DEATH 21b.IF TRANSPORTATION INJURY 210.WAS AN AUTOPSY PERFORMED?
<br /> K ❑Not pregnant within past year t]Naturel ❑Homicide ❑Driver/Operator [OYES 0 NO
<br /> w ❑Pregnant at Otto of death ❑Accident❑Pending Inveatlgellon ❑Passenger
<br /> V ❑Not pregoanl,but pregnant within 42 d 21d.WERE AUTOPSY FINDINGS AVAILABLE
<br /> aye of death ❑Suicide ❑Could not be determined ❑Pedestrian TO COMPLETE CAUSE OF DEATH?
<br /> -0 ❑Nut pregnant,but pregnant 43 days to 1 year before death ❑Other(Specify) ( YES ❑NO
<br /> qu ❑Unknown U pregnant within the past year
<br /> ri
<br /> Q• 225.DATE OF INJURY(No.,Day,Yr.) 22b.TIME OF INJURY 22e.PLACE OF INJURY-At home,farm,sheet,factory,office building,construction site,etc.(Specify)
<br /> U m
<br /> d
<br /> m
<br /> 22d INJURY AT WORK? 22e.DESCRIBE HOW INJURY OCCURRED
<br /> I- ❑YES ❑NO
<br /> -,.22fLOCATION OF INJURY-STREET a NUMBER,APT.NO. CITY/TOWN STATE ZIP CODE
<br /> 23a.DATE OF DEATH(Mo.,Day,Yr.) 24a.DATE SIGNED(Mo..Day,Yr.) 240.TIME OF DEATH
<br /> I W a'w 5-28-2013 12:26 PM
<br /> 236.DATE SIGNED(Mo.,Day,Yr.) 23c.TIME OF DEATH y O 24.PRONOUNCED DEAD)Mn..Day,Yr.) 24d.TIME PRONOUNCED DEAD m
<br /> tw31 I DI 6 G Q.}J 5-19-2013 I 12:26 PM
<br /> 8.4cc ER<Z m
<br /> o o 23d.To the best of my knowledge,death 000000d at the time,date and place �w z.O 24e.On the basis of examination and/or invests.-'on my opinion death occurred
<br /> o w and due to the causes)stated.(Signature and Title) .5 C=O at the dole,date and place and due to • eau....))stated. Ignawre and Title)
<br /> V o .... .,...."'r-.-* ems'
<br /> 25.DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a.HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b.W CON T GRANTED? �+-,
<br /> ❑YES VINO [I PROBABLY ❑UNKNOWN ❑YES `eL I NO Not psi le if 28a Is NO ❑YES yJ NO
<br /> 27.NAME,'TITLE AND ADDRESS OF CERTIFIER(Type or Print)
<br /> Matthias I. Okoye, M.D., J.D. 6940 Van Dorn St Suite 105 Lincoln, NE 68506
<br /> 28a.REGISTRAR'S SIGNATURE 29b.DATE D BY REGISTRAR(Mo..OeY,Yr.)
<br /> P
<br /> /6(4.14/04 � ! JUN
<br /> ii
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