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To be completed/veritled by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Robert White Lowry 2. SEX Male 3ZDkLEOF DEATH (Mo., Day, Yr.) ; ,,April 26, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Lincoln, Nebraska 5a. AGE - Last Birthday (Yrs.) 87 Sb. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.) October 15, 1926 MOS. DAYS HOURS MINS. / y, 7. SOCIAL SECURITY NUMBER 507 -44 -0215 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient . OTHER ® Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Grand Island Veterans Home ❑ 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 Cairo 9d. STREET AND NUMBER 14576 West White Cloud Road e. APT. NO. r 9f. ZIP CODE I 68824 9g. INSIDE CITY LIMITS ❑ YES is] 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 Iva Zajic 11. FATHER'S -NAME (First, Middle, Last, Suffix) Clarence Amos Lowry 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ida Louise White 13. EVER IN U.S. ARMED FORCES'? Give dates of service If Yes. (Yes, No, or Unk.) Yes 09/18/1944- 07/13/1946 14a. INFORMANT -NAME Iva Lowry 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.) April 28, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 1 To be completed by: CERTIFIER 18. PART 1. Enter the chain of events - -diseases, Injuries, or complications -but directly caused the death. DO NOT enter terminal events such as cardiac arrest. APPROXIMATE INTERVAL onset to death > 1 Year 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) Coronary Artery Disease dlsoase or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: . onset to death Sequentially list conditions, If b) any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (disease or Injury that Initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given In PART I. Chronic Kidney Disease; Diabetes Mellitus Type II. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El 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 0 Could not be 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 S 5 El Y z 23a. DATE OF DEATH (Mo., Day, Yr.) April 26, 2014 g i . Y a. 4 El O o 8 '' $ 8 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) April 28, 2014 23c. TIME OF DEATH ( 07:50 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD O 2d. To the best of my knowledge, death occurred at the time, date and place o and due to the cause(s) sated. (Signature and Title) i Gene L. Wyse, DO 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the causes) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable ff 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Gene L. Wyse, DO, 2300 West Capital Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I April 29, 2014 DATE OF ISSUANCE 05/01/2014 STATE OF NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE CERTIFICATE OF DEATH IlEddbits0 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 DEPARTMENtpF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS 0 ;STANLEY S, COOPED 2014078 4''oDEPARTMENT OF FiEAkTH:AND LINCOLN, NEBRASKA i-HOMAN SERVICES