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- To Be Completed/Verified by: FUNERAL DIRECTOR 1 ------ - - - --- -- - -- - - -- 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Melvin Louis Gappa 2. SEX Male 3. DATE OF DEATH (Mo.,Dey,Yr.) February 10, 2009 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Loup City, Nebraska 5a. AGE -Last Bltthday (Yrs.) 84 6b. UNDER 1 YEAR 6e. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) August 18, 1924 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -22 -9584 8a. PLACE OF DEATH HOSPITAL: ID Inpatient OTHER; ❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) VA Medical Center ❑ ER/Outpatient ❑ Decedent's Home ❑ DoA [3 other(Specify) B. CITY OR TOWN OF DEATH (include Zip Code) Omaha 68105 6d. COUNTY OF DEATH Douglas 9e. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1214 N. Wheeler Ave. 90. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® Yea ❑ No 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 1Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) I wife, give maiden name. ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Elna M Malmgren 11. FATHER'S -NAME (First, Middle, Last, Suffix) Peter Gappa 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Frances Mendyk 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 08/30 1945 - 02/17/1953 14a. INFORMANT -NAME Elna M Gappa 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION El Buda! ❑°°°°"°° ® Cremation ❑Entombment ❑Removal ❑Other(speeity) 18a. EMBALMER-SIGNATURE Not Embalmed 16b. LICENSE NO.' 16c. DATE (Mo., Day, Yr.) February 12, 2009 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE Autumn Hills Crematory Omaha ' Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Kleine Funeral Home, 3213 W. North Front Street, Grand Island, Nebraska 17b. Zip Code 68803 To Be Completed by: CERTIFIER CAUSE OF DEATH (See instructions and examples) 1e. PART I. Enter the chain of events - diseases, Injuries, or complications- that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final disease or condition resulting a) a L ,. _. u� in death) r 1's Pi�( . u�i 3b IA9 WII DUE TO, OR AS A C EQUENCE OF); onset to death Sequentially list conditions, 11 any, leading to the cause listed b) ie., .54/bat i IA no_ per, 1, 14 S i n `WI on line a. DUE TO, R AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE e) (disease or injury that initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART IL OTHER SIGNIFICANT CONDITI01 S- Conditions contributing to the death but not resulting In the underlying cause given In PART I. 5- L nnprblY+q 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 20. IF MALE: ['Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death t ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑Unknown if pregnant within the past year 21a. MANNER OF DEATH , Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? KYES ❑ NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO CO COMPLETE CAUSE OF DEATH? DYES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, fa m, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET 8. NUMBER, APT. NO. CITYITOWN STATE ZIP CODE To be completed by Attending PHYSICIAN ONLY ' 235. DATE OF DEATH (Mo., Day, Yr.) elli4 lZO(� 2 24a. DATE SIGNED (Mo., Day, Yr.) A' 24b. TIME OF DEATH m 23b.,DATE SIGNED (Mo., Day, Yr.) 624 i 2 2 23c. TIME OF DEATH D6 ^ m 2� R r. 9t y O 24c. PRONOUNCED DEAD (Mo., Day, Yr.) I E S -1 a z 24d. TIME PRONOUNCED DEAD m 934 Toth b st f knowled e, death occurred a t the time, date and l ace � 9 p my g p and due to the cause(a) stated.`(Signei u e anti Title 0 O W � 124a On the beats of examination and/or Investigation, In my opinion death occurred a z0 =O at the time, date and place and due to the cause(s) stated. (Signature and Title) ci , 1 � r 25. DID TOB4 CO ISO CONTRIBUTE TO THE DEATH? ❑ YES ` 14510 ` LI PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ha YES ❑ NO 26b. WAS CONSENT GRANTED? Not Applicable 11 28a is NO ❑ YES N 27. NAME, TITLE 'AND ADIR SS OFCERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) ,r / �i /I J � C f 4 . s J A2 vet �- ' .Q ' / /dog /4 / f e Wd 7 ;0 , V e tY �lA , GP P I 28a. REGISTRAR'S SIGNATURE .e""' " , ILQ a toVird 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) FEB 12 2409 334115 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES This certifies this document to be a true copy of an original record on file with Vital Statistics, Douglas County Health Dept. Omaha, Nebraska. Certified copies must have a raised seal in the area to the left. Reproductions of this green certificate are not legal copies. Date Issued: to .= t Registrar: 201308790