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To be completed/verlfied by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Ronald Bruce Bailey 2. SEX ` •_?` - Male � ' -'!' . I J. DATE OF DEATH (Mo., Day, Yr.) ' December 6, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Mount Pleasant, Iowa 5a. AGE - Last Birthday (Yrs.) 80 5b. UNDER 1 YEAR 5c. UNDERI DAY: 6. DATE bF BIRTH (Mo., Day, Yr.) March 3, 1934 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 485 -32 -8843 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Wedgewood Care Centel ❑ ERiOutpatient ❑ Decedents 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 STREET AND NUMBER 4188 Norseman Av e. APT. NO. re. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS 0 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 Willa Jean McAndrews 11. FATHER'S -NAME (First, Middle, Last, Suffix) Bernard B Bailey 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Marjorie Mae Donald 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 09/17/1956- 08/27/1958 14a. INFORMANT -NAME Willa Jean Bailey 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Patricia R. Curran 16b. LICENSE NO. 1092 16c. DATE (Mo., Day, Yr.) December 13, 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) Curran Funeral Chapel, 3005 S. Locust St., 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, 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) Chronic Kidney Disease disuse or condition resulting onset to death Years in death) DUE TO, OR AS A CONSEQUENCE OF: ' onset to death Sequentially list conditions, If b) Diabetes Mellitus i Years any, leading to the cause listed 1 1 line on 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 1 1 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given In PART I. Hypertension, Hyperlipidemia, Coronary Artery Disease, Peripheral Vascular 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 ❑Accident 0 Investigation Suicide Could not W 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? TO ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY r 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? OYES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE B g 1 i= E o Z o 23a. DATE OF DEATH (Mo., Day, Yr.) December 6, 2014 a § 1 $ ° ° ° a 0 a z O 2 V 8 ~ u a 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) December 9, 2014 123c. TIME OF DEATH 08:43 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 a O 3d. To the best of my knowledge, death occurred at the time, date and place 12 and d to the cause(*) stated. (Signature and Title) 2 Jay C. Anderson, MD 24e. On the basis of examination andlor investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 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 Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE A - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 12, 2014 DATE OF ISSUANCE 12/15/2014 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 NEB RASK 6DENTRTV NT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR WI AEG° QS" 20150082 COOPER ASSJSTANT STATE REG.nnTRAR' DEPtIRT t H ALTH 4ND . LINCOLN, NEBRASKA , HOMAN''CE -•f STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER 4l ES t r 1 CERTIFICATE OF DEATH ° ' ,:*-(46 14 06402