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L To be completed by: CERTIFIER I I To be completedlverified by: FUNERAL DIRECTOR I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Jerry Dean Jones 2 SEX' , •., i , : ,, Male ^ ,3, OF dEATH (Mo., Day, Yr.) .`. July 23 014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Clay Center, Nebraska 5a. AGE - Last Birthday (Yrs.) 81 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 8 DATEIOF BIRTH (Mo., Day, Yr.) -. ' • s February 9, 1933 MOS. DAYS HOURS MINS 7. SOCIAL SECURITY NUMBER 506 -34 -2345 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Home ❑ DOA ❑ Other (Specify) 8b. FACILITY -NAME (If not Institution, give street and number) 208 Lakeside Dr 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 208 Lakeside Dr '9e. APT. NO. 8f. ZIP CODE f 68801 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 Barbara Culp 11. FATHER'S -NAME (First, Middle, Last, Suffix) Raymond C Jones 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Julia Knutson 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 08/06/1953- 06/10/1955 14a. INFORMANT -NAME Barbara Jones 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.) July 29, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) IL 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, r 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) Chronic Obstructive Pulmonary Disease Years disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death Sequentially list conditions, if b) 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 I. the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death LAST d) 1 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? ❑ 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 Accident Pending Investigation ❑ ❑ ❑ Suicide ❑ Could not be 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.) 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 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE 3'W i i r I u z 23a, DATE OF DEATH (Mo., Day, Yr.) July 28, 2014 S $ g _ O. 1 a: z cal 0 U .2 15 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) July 30, 2014 23c. TIME OF DEATH I 10:56 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD o g 0 3d. To the best of my knowledge, death occurred at the time, date and place y P a and due to the causes) stated. (Signature and Title) x Travis S. Hageman, MD 24e. On the basis of eaamination ■ndlor investigation, in my opinion dear occurred at the time, date and place and due to the caueals) stat (Sig end Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? M YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 28a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 1 28a. REGISTRAR'S SIGNATURE - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) August 4, 2014 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, RECORDS. 08/06/2014 DATE OF ISSUANCE 201406766 ST E' . COOPER ASSISTANT STATE R'EGXSTRf R DEPARTMENT" "OF HEALTH'AN LINCOLN, NEBRASKA HUMANE YICCS- STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN'SERVICES 4*" ' { /_. . -� CERTIFICATE OF DEATH • 14 03827