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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Elmer Lee Layher 2. SEX • 1 `' ,l' Male . ' '✓r 3: DATEOF D)`OH,(Mo., Day, Yr.) / i,Juli 1, 2014" 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Cozad, Nebraska 5a. AGE - Last Birthday (Yrs.) 81 5b. UNDER 1 YEAR 5c. UNDER 1 DAY' 6. Dptgdta'BIRTH (Mo., Day, Yr.) May 4, 1933 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -34 -5552 8b. FACILITY -NAME (If not Institution, give street and number) 307 West 11th Street 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ID Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH I Hall 9a. RESIDENCE-STATE . Nebraska lib. COUNTY Hall 19c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 307 West 11th Street APT. NO. 9f. ZIP CODE I 68801 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) N wife, give maiden name Evelyn A Henry 11. FATHER'S -NAME (First, Middle, Last, Suffix) Elmer R Layher 12. MOTHER'S -NAME (First, Middle, Maiden Sumame) Hazel Beanblossom 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 05/12/1953- 04/15/1955 14a INFORMANT -NAME Evelyn A Layher 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Chris McCoy 16b. LICENSE NO. 1191 16c. DATE (Mo., Day, Yr.) July 7, 2014 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) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 13. PART I. Enter the chain of events - -disuses, injuries, or compllcationsahat directly caused the death. DO NOT enter terminal events such as cardiac amst, ' APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on • line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Cholelithiasis disease or condition resulting onset to death Weeks In death) DUE TO, OR AS A CONSEQUENCE OF: ' onset to death sequentially list conditions, If b)Cirrhosis I Years any, leading to the cause listed i i line on a. DUE TO, OR AS A CONSEQUENCE OF: i onset to death Enter the UNDERLYING CAUSE c) Liver Cancer I Years (disease or injury that initiated the events resulting M death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) I 1 I 18. PART II.OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Systolic Congestive Heart Failure 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 are past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation Suicide not be determined ❑ ❑ 21b. IF TRANSPORTATION INJURY ❑ DriverlOperator ❑ Passenger Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑YES ID NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? DYES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 2 i 23a. DATE OF DEATH (Mo., Day, Yr.) July 1, 2014 S I i <' ,10 hu 3 18 ~ l; 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) July 3, 2014 123c. TIME OF DEATH 10:06 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 0 3e. To the best of my knowledge, death occurred at the time, date and place 2 M and due to the cause(s) stated. (Signature and Title) e 2 Travis S. Hageman, MD 24s. On e basis of examination dlor investigation, in my opinion death occurred d the time, dab 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 if 26a 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 28a. REGISTRAR'S SIGNATURE S - -- _ •�p�V 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) July 7, 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 QEPAItTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITA1' REGQRD$.,,� t, DATE OF ISSUANCE 07/08/2014 LINCOLN, NEB 2015000$3 STAI)1 EY S. COQPER e� ASSISTANT STATE REGISTA4R �° /- 41rrH ANDr, gg n .h.� , ,. DETP TME�I, NEBRASKA HfIMAN SERV STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICg.S CERTIFICATE OF DEATH i "r' •. 6 1; r) ,. 44 03304 • *