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To be completed /verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Donald Berdette Kistler 2. SERA / I s/3.�. Male ' °T )F DEATH (Mo., Day, Yr.) F 61.701ify14, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Shelton, Nebraska 5a. AGE - Last Birthday (Yrs.) 93 5b. UNDER 1 YEAR 5c. UNDERI DAY ' 6. DATE,OF OWN (Mo., Day, Yr.) July 15, 1921 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -14 -6479 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis ❑ 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 Grand Island 9d. STREET AND NUMBER 523 W. 9th Street 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ID Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Alice Henrietta Katherine Wagner 11. FATHER'S -NAME (First, Middle, Last, Suffix) Roy Samuel Kistler 12. MOTHER'S -NAME (First, Middle, Malden Surname) Margaret Kendall 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Alice Henrietta Katherine Kistler 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.) February 17, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code I 68801 CASE OF DEATH (See instructions and examples) To be completed by: CERTIFIER Is. PART I. 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) Cerebral Vascular Accident disease or condition resulting onset to death 12 Hours M death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death sequentially list conditions, if b) I any, leading to the cause listed I 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: I onset to death LAST d) 1 i 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 1 20. IF FEMALE: ❑ Not pregnant within pest 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 ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ DrverlOperator ❑ Passenger ❑ Pedestrian ❑ Other (specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ®NO 21 d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ 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? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE E' 5 F ° 6 Z 23a. DATE OF DEATH (Mo., Day, Yr.) February 14, 2015 p �' 1 rc 2 3b. . ° ( 4 y E o. Q11 ` o ' W 5. Z O 8 z 8 o O U ~ 8 6 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH DATE SIGNED (Mo., Day, Yr.) February 16, 2015 23c. TIME OF DEATH 08:40 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD u ¢ O 3d. To the best of my knowledge, death occurred at the time, date and place 2 c and due to the cause(s) stated. (Signature and Title) 0 - f Ryan D. Crouch, 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(s) 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 PrHnt Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803 r 28a. REGISTRAR'S SIGNATURE /1r i l A - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) February 18, 2015 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH & AN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR,4 Rosa C OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOROITAt DATE OF ISSUANCE 20150165 "As5rs DkeAP LINCOLN, NEBRASKA 11L#1,4 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN CERTIFICATE OF DEATH 02/23/2015 .r 4 • , . '71 AF 1,4AI 15 00925