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To be completedNerified by: FUNERAL DIRECTOR 1 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Gordon Leo Dimmitt 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) February 16, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Taylor, Nebraska 5a. AGE • Last Birthday (Yrs.) 87 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) December 13, 1925 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -28 -0533 8b. FACILITY -NAME (If not Institution, give street and number) Grand Island Veterans Home 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 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 STREET AND NUMBER 419 North Carey re. e. APT. NO. 9f. ZIP CODE f 68803 9g. INSIDE CITY LIMITS I ® 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) If wife, give maiden name Glendora May Murray 11. FATHER'S -NAME (First, Middle, Last, Suffix) Jack Dimmitt 12. MOTHER'S -NAME (First, Middle, Malden Surname) Ruth Fox 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 01/19/1949- 01/19/1950 14a. INFORMANT -NAME Glendora May Dimmit 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) February 19, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See Instructions and examples) To be completed by: CERTIFIER 18. 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 onset to death > 1 Year respiratory arrest, or ventricular fibrillation without showing the etiology, DO NOT ABBREVIATE. Enter only one cause on a Tine. Add additional Tines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Coronary Artery Disease disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) any, leading to the cause listed on line 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. Diabetes Mellitus Type 2 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 20. IF FEMALE: El Not pregnant within past year P - ❑ Pregnant at time of death me oeat ❑ 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 II NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE S i P tJ 23a. DATE OF DEATH (Mo., Day, Yr.) February 16, 2013 11 i >. k y Ely t 8 W 2 1 8 '' $ 5 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b DATE SIGNED (Mo., Day, Yr.) February 19, 2013 23c. TIME OF DEATH 02:10 PM 24e. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD B 3d. To the bat of my knowledge, death occurred at the time, date and place 2 S and due to the cause(s) stated. (Signature and Title) a Gene L. Wyse, DO 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 USE CONTRIBUTE TO THE DEATH? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Gene L. Wyse, DO, 2300 West Capital Avenue, Grand Island, Nebraska, 68803 28a, REGISTRAR'S SIGNATURE A � j �� + l M l 28b, DATE FILED BY REGISTRAR (Mo„ Day, Yr,) February 19, 2013 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH'AND HJJIt1AN ERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITA d 'IRQS. 201401654 srAkE A )ST.Q 71S R5G7STRAR DEPARTMENT OF HEALTH A ND LINCOLN, NEBRASKA HolA(tI E RVICES ' STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SI:RVtCES • Ca ( t CERTIFICATE OF DEATH DATE OF ISSUANCE 02/22/2013