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To Be Completedlverifled by: FUNERAL DIRECTOR 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Larry Everson Dyer 2. SEX Male _ 355 DAt'TF OGDEAtrH`t Mo.tDay;(n) Stily 61V3 '._ , " ,. , 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sumner, Nebraska 5a. AGE -Last Birthday (Yrs.) 73 5b. UNDER 1 YEAR 5c. UNDER 1 DAY. 6. DATE OF BIRTH (lto., Day, Yr.) MOS. DAYS HOURS MINS. January 10, 1940 7. SOCIAL SECURITY NUMBER 507 -48 -4379 8a. PLACE OF DEATH HOSPITAL4 NI Inpatient QB &;❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home 0 DOA ❑Other(Specify) 8b. FACILITY -NAME (If not Institution, give street and number) Veterans Affairs Medical Center 8c. CITY OR TOWN OF DEATH (include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 3949 West Capital Avenue 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® Yea ❑ No 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Janice Come 11. FATHER'S -NAME (First, Middle, Lest, Suffix) Roy A Dyer 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Leona Everson 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or link.) Yes 08/07/1963- 07/22/1965 14a. INFORMANT -NAME Janice Dyer 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ID Curial ❑Donatbn ID Cremation ❑Entombment ❑Removal ❑Other(Speclty) 16a. EM ` /get O ]'' ( /1.t /V 16b. LICENSE NO. L3,225 16c. DATE (Mo., Day, Yr.) July 29, 2013 16d. CEMETE CREMATORY OR O ER LOCATION CITY/TOWN STATE Sumner Cemetery Sumner Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 To Be Completed by: CERTIFIER ( CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the EgigI of eeenta • diseaese, intud.e, or complications. that direetty caused the death. DO NOT enter terminal events such n cardiac sweat, APPROXIMATE INTERVAL onset to death respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only on cause one line. Add additional lines if neaesary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final \ - disease or condition resulting a) (7 0.`-6 1 ' &_ Sr .\ Q. C\� \ N ��\ v,cc... in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If \ 1 \- � l �a' .`} \,, any, leading to the cause listed b) y\-- \t3. \ , `J ,,il \l, o \ W t 1 ' 1 t A R0. �' . RC, on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) �� C SCR.. C (disease or Injury that initiated the events resulting in death) DUE TO, OR AS A CON UENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. \ �y 1 ("\-% � c\ \ 0. t X e�1 � e C Q ,C) C I" 1\ � e c � \ �"COI..`�`Q 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑YES NO - i } 20. IF FEMALE: ❑ Not pregnant within past year ❑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 21a. MANNER OF DEAN atursl ❑ Hot ❑ Ac 'dent 0 Pending investigation ❑ Suicide ❑ Could not be determined Igb. IF TRANSPORTATION INJURY ❑ Driver /Operator 0 Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 9' NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? _�,iit1,,,� ❑ YES NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 22c. PLACE C come, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE tE q F � Z g 2 I 12 N i � 23a. DATE OF DEATH (Mo., Day, Yr.) 'i■Al Ir- a 5' . & ()I:') To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH m 23b. DATE SIGNED (Mo., Day, 4r.) e a y AL\ a t n 23c. TIME OF DEATH 0021 A. m 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD m 23d. To the apt of my krFgNifed e, death occurred at the time, date and place ue to the utte(s) st ted:(Signature and Title) )d' m d, ca / / 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO 1�9E CONTRIBUTE TO THE •'" ❑ YES ❑l0 PROBABLY ..,❑.UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 1g NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES k( NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) . _ A "n.c‘k) \eV.i \eZ. `CRO Y mC , aaaLi4 kocTi vie ll (4 ocl :ts\ )d N obcctc a Vet)) P 28a. R ISTRAR'S SIGNATURE 28b DATE FILED BY REGISTRAR (Mo., Day, Yr.) AUG 2 2013 , WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANC SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA D 5aRTMC-fiIt tOPI EALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAI:'RECQI I S I ' t t DATE OF ISSUANCE AUG 13 2013 LINCOLN, NEBRASKA STATE OF NEBRASKA 201306985 ST4AILEY,t D OPER ASSISTANT STATE RTGISTRA-R DEPARTMENf O --lE TV AND HUI IA I $ERViCCS' STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH :.