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To be completed/verlfied by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Glen Eugene Hallner 2. SE4 '' r , , • Male < , 3. DATE0F DEATH (Mo., Day, Yr.) December 5, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Ericson, Nebraska 5a. AGE - Last Birthday (Yrs.) 79 5b. UNDER 1 YEAR 5c. UNDER 1 DAY a. BATE OF BIRTH (Mo., Day, Yr.) February 3, 1935 MOS. DAYS HOURS MINE. 7. SOCIAL SECURITY NUMBER 505 -36 -3184 8b. FACILITY -NAME (If not Institution, give street and number) Mary Lanning Healthcare 8e. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/outpadent ❑ Decedent's Home ❑ DOA ❑ Other(Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Hastings 68901 8d. COUNTY OF DEATH I Adams 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 4255 Pennsylvania Avenue 19e. APT. NO. 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 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Nelda Marie Handel 11. FATHER'S -NAME (First, Middle, Last, Suffix) Cecil E Hallner 12. MOTHER'S -NAME (First, Middle, Malden Sumame) Mabel Gray 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 02/29/1956- 12/18/1958 14a. INFORMANT -NAME Nelda Marie Hallner 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation [] Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) December 10, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Cemetery Grand Island 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) To be completed by: CERTIFIER 18. PART 1. Enter the chain of events -- diseases, Murie', or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, r 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) Parkinsons disease or condition resulting onset to death Chronic In death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b)Pneumonia 1 1 Week any, leading to the cause listed I 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) 1 (disease or Injury that initiated . the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) 1 r 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 ❑ 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 21 MANNER OF DEATH IGt Natural ❑ Homicide 0 Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be detemiined 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21e. WAS AN AUTOPSY PERFORMED? ❑ YES i7 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. CITY/TOWN STATE ZIP CODE W I '' r § i 23a. DATE OF DEATH (Mo., Day, Yr.) December 5, 2014 z S g ote a E k i' a c 0 ... Z 2 g g ~ g 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b DATE SIGNED (Mo., Day, Yr.) December 10, 2014 23c. TIME OF DEATH I 07:05 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 2 W and due to the cause(s) stated. (Signature and Title) f Zach Frey, 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 cause( *) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? I26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN I ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Zach Frey, DO, 223 E 14th St., Suite 100, Hastings, Nebraska, 68901 128a. REGISTRAR'S SIGNATURE - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 11, 2014 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HOALTH A 1 (D H UMANtSERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA 64 'Mi'Mfr OF HEALTH. AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOi T7IT.4 p, 2kCORQS. DATE OF ISSUANCE 12/15/2014 21506221 1 ter:' .� .. s, ANLEYS.- COAPER •. ASSIST sr TE gar's EVPAR7dJ��LH <tAVLB� LINCOLN, NEBRASKA l{UMAN 'SWIG STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMA4E1 VIQES,, `' - CERTIFICATE OF DEATH + S r 6' .f 14 06364