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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTj AArD WPM SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA pARAIITM NT tOF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VI14I RECOR ' DATE OF ISSUANCE 07/09/2013 LINCOLN, NEBRASKA 20100045 . STANLEY S. COOPER " . ASSIS EGJ$7`fi 4 DEPAR71 J OOHEALT11 <.IAID; HUMAN SERVICES • STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE F n, ! °I • 13 02854 CERTIFICATE OF DEATH 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Lyle Berdett Kemp 2. SEX I, a ' / ' Male 3. DATE OF DEATH (Mo., Day, Yr.) , 22, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Glenvil, Nebraska 5a. AGE - Last Birthday (Yrs.) 86 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) September 18, 1926 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506-28 -3633 8b. FACILITY -NAME (If not Institution, give street and number) 2550 North St. Paul Road 8a. PLACE OF DEATH HOSPITAL, ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 0 ER/Outpatient ® Decedent's Home ❑ DOA ❑ Other (Specify) • Grand Island 68801 I 8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska Bb. COUNTY Hall 9c. CITY OR TOWN Grand Island 8d. STREET AND NUMBER 2550 North St. Paul Road e. APT. NO. r St. ZIP CODE 68801 9g. INSIDE CITY LIMITS M 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 Shirley Ann Blair 11. FATHER'S -NAME (First, Middle, Last, Suffix) Alvin Kemp 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Emma Johnson 13. EVER IN U.S. ARMED FORCES? Glve dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Jennifer May 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) June 27, 2013 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) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 111. PART I. Enter the chain of events - .diseases, injuries, or compliationsthat 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: onset to death IMMEDIATE CAUSE (Final a)Abdominal Aortic Aneurysm Weeks disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, it b) any, leading to the cause listed line on 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. Prostate Cancer, Heart Disease 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 0 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 ® 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 g Y i 23a. DATE OF DEATH (Mo., Day, Yr.) - Y 1 E & a. < o C E 2 g 0 & � q o 24a. DATE SIGNED (Mo., Aay, Yr.) ' June 25, 2013 24b. TIME OF DEATH 07:00 PM 23b. DATE SIGNED (Mo., Day, Yr.) 123c, TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) June 22, 2013 24d. TIME PRONOUNCED DEAD 08:40 PM 0 3 d. To the best of my knowledge, death occurred at the time, date and place 8 g and due to the cause(s) s stated. (Signature and Title) F W 24e the timee, date the , date annd d place of a an d due t a due t o r the i the ausse(s) e st and oSig ated. (Sign atat ure re and occurr the anaj t Titkla) le) at Dave Medlin, Hall Deputy County Attorney 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 Dave Medlin, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 128a. REGISTRAR'S SIGNATURE - / 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) July 5, 2013 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTj AArD WPM SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA pARAIITM NT tOF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VI14I RECOR ' DATE OF ISSUANCE 07/09/2013 LINCOLN, NEBRASKA 20100045 . STANLEY S. COOPER " . ASSIS EGJ$7`fi 4 DEPAR71 J OOHEALT11 <.IAID; HUMAN SERVICES • STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE F n, ! °I • 13 02854 CERTIFICATE OF DEATH