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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Elmer F Gartner 2. SEX Male 3: DATE OF DEATH (Mo., Day, Yr.) October 31, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Hastings, Nebraska 5a. AGE - Last Birthday (Yrs.) 81 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Ma 24, 1932 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505-44 -4008 8b. FACILITY -NAME (If not Institution, give street and number) 10315 N Aspen Avenue 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) Hastings 68901 8d. COUNTY OF DEATH Adams 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Adams 9c. CITY OR TOWN Hastings 9d. STREET AND NUMBER 10315 N Aspen Avenue 19e. APT. NO. I 18f. ZIP CODE 68901 19g. 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 Lola Marks 11. FATHER'S -NAME (First, Middle, Last, Suffix) Henry Gartner 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Fannie Janssen 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 12/10/1952-09/21/1954 14a. INFORMANT -NAME Lola Gartner 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE James M. McLaughlin 16b. LICENSE NO. 951 16c. DATE (Mo., Day, Yr.) November 5, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Greenwood Cemetery Trumbull Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston - Butler - Volland Funeral Home, 1225 N. Elm, Hastings, Nebraska 17b. Zip Code 68901 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER I 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 Immediate 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) Respiratory Arrest disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death Sequentially list conditions, if b)Chronic Obstructive Pulmonary Disease I any, leading to the cause listed I 1 on line a DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) I (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) 1 1 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? II YES ❑ 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 ❑ A ccident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator Passenger ❑ Pedestrian ❑ Other (Speciry) 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.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 2f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 2. W F W 23a. DATE OF DEATH (Mo., Day, Yr.) y 2 I 3 E ° a < = o w z O B p 8 a 24a. DATE SIGNED (Mo., Day, Yr.) November 12, 2013 24b. TIME OF DEATH 11:00 PM 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) November 1, 2013 24d. TIME PRONOUNCED DEAD 12:57 AM 0 ¢ 2d. 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) 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) Donna Fegler Daiss, Adams County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? I26a. ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN HAS ORGAN OR ❑ YES DONATION BEEN CONSIDERED? Igl NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Donna Fegler Daiss, Adams County Attorney, 500 W 4th St., PO Box 71, Hastings, Nebraska, 68901 28a. REGISTRAR'S SIGNATURE - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) November 13, 2013 STATE OF NEBRASKA 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 RECOROSi DATE OF ISSUANCE 291405176 STANLEY S. tobPER‘ ASSISTANT S'r^ATE REGISTRAR' DEPARTMENT QF HEALTH AND LINCOLN, NEBRASKA HUMAN SERVICS 11/18/2013 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH • 13 04860