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DATE OF ISSUANCE STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAJ,00 6 THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEI. DEPTM HUMAN SERVICES, V I T A L RECORDS O F F I C E , W H I C H I S T H E LEGAL DEPOSITORYS ) ,V t1AL.RECQI (4S 10/18/2013 i SFAN Co 201309835 trD T x cpEPART , LINCOLN, NEBRASKA ,ta 11441 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S RvIG P © 1? A ;, CERTIFICATE OF DEATH 1 `L' 1 "" N SERVICES, IT CERTIFIES T OF HEALTH AND cT EG7S R► R ALTN -14ND 13 04404 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Glen Arthur Gascho 2. SO 4 . , " ' Male ' " 3. DATE OF DEATH (Mo., Day, Yr.) ` October 13, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Hall County, Nebraska 5a. AGE • Last Birthday (Yrs.) 92 5b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) May 21, 1921 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -32 -9074 8b. FACILITY -NAME (If not Institution, give street and number) Good Samaritan Society -Wood River 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatlent ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Wood River 68883 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Wood River 9d. STREET AND NUMBER 1401 East Street e. APT. NO. r 8f. ZIP CODE I 68883 9g. INSIDE CITY LIMITS ® YES ❑ 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) H wife, give maiden name Delores Schweitzer 11. FATHER'S -NAME (First, Middle, Last, Suffix) Arthur Gascho 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Barbara Stutzman 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Glenda Beckler 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Chris McCoy 16b. LICENSE NO. 1191 16c. DATE (Mo., Day, Yr.) October 17, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Wood River Mennonite Cemetery Wood River 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 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events-diseases, Injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death 6 Months respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Inc. I Add additional lines If necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Failure To Thrive disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Bladder Cancer 6 Months any, leading to the cause listed Tina on a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE C ) (disease or Injury that Initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE 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. Asthma 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 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 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? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 122b. TIME OF INJURY 22c. PLACE OF INJURY -At home, 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 1 i } t d 1 23a. DATE OF DEATH (Mo., Day, Yr.) October 13, 2013 S i ,92 i N C E < 8 O 8 g 5 '" s 24a. DATE SIGNED (Mb., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) October 16, 2013 23c. TIME OF DEATH 02:20 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) _ 24d. TIME PRONOUNCED DEAD 3d. To the best of my knowledge, death occurred at the time, date and place 2 and due to the cause(s) stated. (Signature and Title) 1 Ryan D. Crouch, DO 24e. On INC basis of examination and/or Investigation, In my opinion death occurred at the time, date and place and due to the cause(a) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable tf 28a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803 I28a. REGISTRAR'S SIGNATURE / _ fi r l_.i OOJY� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I October 16, 2013 DATE OF ISSUANCE STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAJ,00 6 THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEI. DEPTM HUMAN SERVICES, V I T A L RECORDS O F F I C E , W H I C H I S T H E LEGAL DEPOSITORYS ) ,V t1AL.RECQI (4S 10/18/2013 i SFAN Co 201309835 trD T x cpEPART , LINCOLN, NEBRASKA ,ta 11441 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S RvIG P © 1? A ;, CERTIFICATE OF DEATH 1 `L' 1 "" N SERVICES, IT CERTIFIES T OF HEALTH AND cT EG7S R► R ALTN -14ND 13 04404