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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 . Rt'CORDS DATE OF ISSUANCE 201407446 u OP ER 12/31 /2013 sTrN[r S. EOOP ASSISTANT STATE REGISTRAR. DEPARTMENT OF HEALTH AND LINCOLN, NEBRASKA HUMAN SERVICES!_ ; i •+ ; 4 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIi;ES. 3 05637 CERTIFICATE OF DEATH 1. DECEDENTS -NAME (First, Middle, Last, Suffix) John Andrew Heuer 2. SEX ' / , . , Male ' ' .!t; 'S: GATE Q0•DF r A:rti (MO:, Day, Yr.) „Obcemtfe• 4 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Buford, Georgia 5a. AGE - Last Birthday (Yrs.) 76 5b. UNDER 1 YEAR 5c. UNDER 1' DAY 6. DATE OF J 3IRTH (Mo., Day, Yr.) ' ". May 27, 1937 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -50 -1005 8b. FACILITY -NAME (if not Institution, give street and number) Tiffany Square Care Center 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) 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 3020 Orleans Dr. 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 lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Darlene Glinsmann 11. FATHER'S -NAME (First, Middle, Last, Suffix) Henry Heuer 12. MOTHER'S -NAME (First, Middle, Malden Surname) Katherine Cichacki 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Darlene Heuer 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Katie M. Ewald 16b. LICENSE NO. 1454 16c. DATE (Mo., Day, Yr.) December 28, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Cemetery Grand Island 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) 1a. 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 Colon Cancer To Liver 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) I any, leading to the cause listed I I 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: i 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 I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 13 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 0 Pending Investigation ❑ suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 13 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 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE k W 1 F § o z 23a. DATE OF DEATH (Mo., Day, Yr.) December 25, 2013 z . g 2 t z z B p p ~ 0 3 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) De 30 2013 23c. TIME OF DEATH I 03:45 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD g Y 0 3d. To the best of my knowledge, death occurred at the time, date and place o and due to the cause(s) stated. (Signature and Title) 2 William Landis, MD 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the camels) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN 26a. HAS ORGAN OR nssuE DONATION BEEN CONSIDERED? ❑ YES 13 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print William Landis, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 30, 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 . Rt'CORDS DATE OF ISSUANCE 201407446 u OP ER 12/31 /2013 sTrN[r S. EOOP ASSISTANT STATE REGISTRAR. DEPARTMENT OF HEALTH AND LINCOLN, NEBRASKA HUMAN SERVICES!_ ; i •+ ; 4 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIi;ES. 3 05637 CERTIFICATE OF DEATH