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19a. To be completed by: CERTIFIER 1 1 To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) - Doyle Eugene Denney 2. SEX r Male o ", � ., AATtdF 1ATH (Mo., Day, Yr.) ` A 24, 2015 ' It. 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Onawa, Iowa 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 p'AY v BATE OF BIRTH (Mo., Day, Yr.) (Yrs.) 70 MOS. DAYS HOURS MINS. April 28, 1945 7. SOCIAL SECURITY NUMBER 481 -54 -7919 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ® 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 RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 145 Ponderosa Drive 9e. APT. NO. 9f. ZIP CODE 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 (Flat, Middle, Last, Suffix) H wife, give maiden name Melanie Faye Nieveen 11. FATHER'S -NAME (First, Middle, Last, Suffix) Floyd Denney 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ida Martin 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Melanie Faye Denney 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Steve Chapman 16b. LICENSE NO. 1375 16c. DATE (Mo., Day, Yr.) August 28, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Pella Cemetery Adams 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) 1s. 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: onset to death IMMEDIATE CAUSE (Final a) Undetermined Natural Causes Hour di or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, N b) I any, leading to the cause listed I I on line a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) I (disease or Injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST 1 d) 1 1 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Decedent Collapsed At Home. Cyanotic. Ventricular Fibrillation. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El 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 ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El 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 ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE t rc r i u z 23a. DATE OF DEATH (Mo., Day, Yr.) Z I g € 4 " W a 2 a O ~ 8 o 24a. DATE SIGNED (Mo., Day, Yr.) September 10, 2015 24c. PRONOUNCED DEAD (Mo., Day, Yr.) August 24, 2015 24b. TIME OF DEATH 11:43 PM 24d. TIME PRONOUNCED DEAD 11:43 PM 23b. DATE SIGNED (Mo., Day, Yr.) I23c. TIME OF DEATH u J O 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature nd Title) 1 1 24a. On the basis of azami and/or investigation, y opin de ocmd at the time, date and pla ce nation and due to the causes) state m d. (Sign an d Titi Dave Medlin, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN 26a. HAS ORGAN OR ❑ YES SSUE DONATION BEEN CONSIDERED? 17 NO 28b. 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. Grand Island, Nebraska, 68802 28a. REGISTRAR'S SIGNATURE ... �� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) September 10, 2015 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH A T(D HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASla DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FVI,fREO(RDS. DATE OF ISSUANCE 09/10/2015 LINCOLN, NEBRASKA STATE OF NEBRASKA 201506434 " STANLEY S. COOPER ASSISTANT -STA TWREGIS DEPARI p HEALTH HUMAN SERVF STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE'S. CERTIFICATE OF DEATH