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DATE OF ISSUANCE 07/17/2013 LINCOLN, NEBRASKA STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL HANQ HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE S�1.QEPIVY - WENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY 1 ftLPJCQl2QS� 'y t . 201402508 STANLEY'S.. COOPER `. A SS P T STATE REG7'3T4AR bEP N7' O! LT(EALTH AND ", ,HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICO- - , CERTIFICATE OF DEATH 13 03022 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) John Andrew Jones 2. SEX Male 3. DATE - OF DEATH (Mo., Day, Yr.) July 12, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Cambridge, Nebraska 5a. AGE - Last Birthday (Yrs.) 82 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) September 17, 1930 MO3. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -26 -6415 8b. FACILITY -NAME (If not Institution, give street and number) 1220 Plantation Place 8a. PLACE OF DEATH HmSPIT LA ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatlent ® 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 9e. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1220 Plantation Place e. APT. NO. r 9f. 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 Dorothy Anne Rothmeyer 11. FATHER'S -NAME (First, Middle, Last, Suffix) Thomas P Jones 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Josephine Hougnon 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 01/03/1951- 11/08/1954 14a. INFORMANT -NAME Dorothy Anne Jones 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Patricia R. Curran 16b. LICENSE NO. 1092 16c. DATE (Mo., Day, Yr.) July 16, 2013 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OPDEATH (See instructions and examples) 18. PART I. Enter the ;halo of events - diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac anest, . APPROXIMATE INTERVAL 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: onset to death IMMEDIATE CAUSE (Final a) Mesothelioma Of Lung 8 Months disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, it b) any, leading to the cause listed on inc I 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 11. OTHER SIGNIFICANT CONDITIONS- Conditlons contributing to the death but not resulting In the underlying cause given in PART!. 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 49 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 ❑ DrIwNOperator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY 22e. 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 �5 1 i Y / c„, z 23a. DATE OF DEATH (Mo., Day, Yr.) July 12,2013 24i 110 Y E a 4 8 i i O 8 X p ~ 3 6 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) July 16, 2013 I 23c. TIME OF DEATH 05:40 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 4 0 9d. To the best of my knowledge, death occurred at the time, date and place 2 g and due to the cause(s) stated. (Signature and Title) '.. M Gary Settje, MD 2M. On the basis of examination and/or investigation, In my opinion death occurred at the time, date and place and due to the causes) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES I NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO 261). WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Gary Settje, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 128a . REGISTRAR'S SIGNATURE /�J. A. , ` DATE FILED BY REGISTRAR (Mo., Day, Yr.) I July 16, 2013 DATE OF ISSUANCE 07/17/2013 LINCOLN, NEBRASKA STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL HANQ HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE S�1.QEPIVY - WENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY 1 ftLPJCQl2QS� 'y t . 201402508 STANLEY'S.. COOPER `. A SS P T STATE REG7'3T4AR bEP N7' O! LT(EALTH AND ", ,HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICO- - , CERTIFICATE OF DEATH 13 03022