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To be completedNerified by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) James Lee Gabel 2. SEX 3 Male It :DATE OF ' DEATH (Mo., Day, Yr.) ..OptQbew2, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Scottsbluff, Nebraska 5a. AGE • Last Birthday (Yrs.) 58 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) November 24, 1953 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -78 -0472 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Fillmore County Hospital ® ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Geneva 68361 8d. COUNTY OF DEATH Fillmore 9a. RESIDENCESTATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 4208 Pennsylvania Ave e. APT. NO. r 8f. ZIP CODE I 68803 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) If wife, give maiden name Sandra StrauCh 11. FATHER'S -NAME (First, Middle, Last, Suffix) Raymond Gabel 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Martha Schoeneman 13. EVER IN U.S. ARMED FORCES? Glve dates of service If Yes. (Yes, No, or Unk.) No I 14a. INFORMANT -NAME Sandra Gabel 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) October 6, 2012 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island 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 complicatlons4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death Minutes respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Massive Head Trauma disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Farm Accident Minutes any, leading to the cause listed line on a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Ran Over By Combine Minutes (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 d - ' - but not resulting In the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: ❑ Not pregnant within past year 0 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 ❑ Pen investigation ❑ Suicide ❑ Could determined 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger ® Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 0 N 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) October 2, 2012 22b. TIME OF INJURY 09:25 AM 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) Farm Field 22d. INJURY AT WORK? ® YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED Head ran over by the Combine 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 816 Road 12, Geneva Nebraska 68361 a W E 23b. E u '2' 23a. DATE OF DEATH (Mo., Day, Yr.) October 2, 2012 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH DATE SIGNED (Mo., Day, Yr.) O ctober 5, 2012 23c. TIME OF DEATH I 09:48 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 4 0 9d. To the best of my knowledge, death occurred at the time, date and place c and due to the cause(s) stated. (Signature and Title) 2 Jason L Bespalec, MD 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? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ® YES ❑ NO 26b. WAS CONSENT GRANTED? Not Applicable H 263 is NO ❑ YES ® NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jason L Bespalec, MD, 1323 H Street, P.O. Box 268, Geneva, Nebraska, 68361 128a. REGISTRAR'S SIGNATURE /l / / �rl� / � . +v� r � I � • VQ V �/ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 5, 2012 DATE OF ISSUANCE WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH 4 4A113- PIl1N(A44SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA - D,EP .TMEIV bf',HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR Jl1"T'41LLY ECORDS. { 3 10/22/2012 STATE OF NEBRASKA STANLEY S COOPER 201402282 ASSZSTAN V 714-rE DEPARMME OFW L'F1'I AND LINCOLN, NEBRASKA HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES , . ' - CERTIFICATE OF DEATH '12 03707