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To Be CompletedlVerified by: FUNERAL DIRECTOR - -- - --- - ----- -- - --- --- I. DECEDENTS -NAME (First, Middle, Last, Suffix) N Donald Gannon 2. SEX Male - - - --- 3. DATE OF DEATH (Mo, , r.) April 30, 2008 4. CITY AND STATE. OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5e. AGE -Last Birthday (Yrs.) 60 6b. UNDER 1 YEAR Sc. UNDER 1 DAY 9. DATE OF BIRTH (Mo., Day, Yr.) May 14, 1947 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508-54-2821 6e. PLACE OF DEATH HOSPITAL: ❑ in patient • OTHER: ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient III Decedent's Home ❑ DOA ❑otit.r(speclry) Bb. FACILITY -NAME (If not Inatitudon, give street and number) 2212 Woodridge Lane 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall • 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2212 Woodridge Lane 9e. APT. NO. tit. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® Yes ❑ No 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Barbara Ann Momer 11. FATHER'S -NAME (First, Middle, Last, Suffix) Elmer Gannon 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Lillian Cadwalder 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yea, No, orUnk) Yes - dates unknown 14a. INFORMANT -NAME Barbara Ann Gannon 146. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION . I BteIN ❑Donation ❑Cremation ❑Entombment ❑Removal ❑ Olhegapectiyi 16a. EM ERSIGNATU L(>1 rte . - 18b. LICENSE 2 NO. /t�7 r / 7 16c. DATE (Mo., Day, Yr.) May 5, 2008 16d. C ETERY, 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 To Be Completed by: CERTIFIER CAUSE OF DEATH (See Instructions and examples) 1e. PART L Enter the cNM diumet - diseases, InjurNe, or complications -tat directly sussed the death. DO NOT enter tsmdnal events such as cardiac @nest, I APPROXIMATE INTERVAL Respiratory arrest. or ventricularandlletion without showing the etiology. DO NOT ABBREVIATE. Enter only one awe en • line. Add additional sees ti neceewy. IMMEDIATE CAUSE: I onset to death IMMEDIATE CAUSE (Final 1 disease or condition resulting a) cardiac arrest I unknown In death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death - I any, leading b) heart disease .I unknown on line a DUE TO, OR AS A CONSEQUENCE OF: I onset to death I Enter the UNDERLYING CAUSE c) obesity I Injury that - (disease or Initiated I the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LAST I d) I 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? EYES ❑ 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 153 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? OYES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ® NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY � 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) I 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITYITOWN STATE ZIP CODE a 5 v H E 81 G i I-• Q 23a. DATE OF DEATH (Mo., Day, Yr.) g .'u 24a. DATE SIGNED (Mo., Day, Yr.) May 7, 2008 24b. TIME OF DEATH approximately (midnight) 'after)12 :0O ..: 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH m y 0 g 24c. PRONOUNCED DEAD (Mo., Day, Yr.) April 30, 2008 24d. TIME PRONOUNCED DEAD 6:06 am 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(a) stated. (Signature and Mlle) 3 I z C o C g I - n t.1 6' 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) Hall Count Attor 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? Ej YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDER ❑ YES [] NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Mark J. Younq,.Hall County Attorney, 231 S. Locust Street, Grand Island, NE 68801 P 28a. REGISTRAR'S SIGNATURE •it ff► I '' 2813. DATE FILED BY REGISTRAR (Mo., Day, Yr.) MAY 2 7 2008 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS, DATE OF ISSUANCE JUL 1 8'2014 LINCOLN, NEBRASKA STATE OF NEBRASKA 201405075 STANLEY $ CpO ER ASSISTAN STATER GI DEPARTMENT (IF HEALTH AND HUMAN SERVICES. STATE OF NEBRASKA_ DEPARTMENT OF HEALTH AND HUMAN SERVICES y