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I To be completed/verified by: FUNERAL DIRECTOR 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Jerry Lynn Eubanks 2. SEX, ' t I `/ Male ' ' 3. DATE-OF DEATH (Mo., Day, Yr.) May 9, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Fort Sill, Oklahoma 5a. AGE - Last Birthday (Yrs.) 60 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) August 22, 1953 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 509 -58 -7437 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home /LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Park Place -A Golden Living Center ❑ ER/Outpatient ❑ 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 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2107 West 2nd Street 9e. APT. NO. 114 9f. ZIP CODE 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 11. FATHER'S -NAME (First, Middle, Last, Suffix) Cecil Otis Eubanks 12. MOTHER'S -NAME (First, Middle, Maiden Sumame) Fannie Mae St John 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes Dates Unknown 14a. INFORMANT -NAME Sandra Eubanks 14b. RELATIONSHIP TO DECEDENT Sister 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.) May 14, 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) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) I To be completed by: CERTIFIER 18. 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, 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: IMMEDIATE CAUSE (Final a) Metastatic Gastric Adenocarcinoma disease or condition resulting onset to death 3 Months in death( DUE TO, OR AS A CONSEQUENCE OF: ; onset to death Sequentially list conditions, If b) 1 any, leading to the cause listed 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: i 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: 1 onset to death LAST d) 1 1 1 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Hypertension, Emphysema 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 determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 123a. DATE OF DEATH (Mo., Day, Yr.) - a W May 9, 2014 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY r 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH I t r 23b. DATE SIGNED (Mo., Day, Yr.) I u May 12,2014 23c. TIME OF DEATH I 11:15AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 2 0 0 3d. To the best of my knowledge, death occurred at the time, date and place 0 3 and due to the cause(s) stated. (Signature and Title) 2 Mia J. Hyde, PA 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? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ® YES ❑ NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ® NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Mia J. Hyde, PA, 3016 West Faidley, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE A - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) May 15, 2014 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH, HUMAN' SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEB. 345RA ��1R�T OF HEALTH AND • HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR ((jT)A4 EN L . RD ,, DATE OF ISSUANCE 11/17/2014 LINCOLN, NEBRASKA 201407425 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERF/i4 CERTIFICATE OF DEATH "ANLEY 5.'C'fYOPEI." , -,4SSI T� S AFE:RtGJS'TRXIR DEW. EN? P ALTl- A Q' HUMAN SERVICES;_.' 14 02369