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To be completed /verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Gerald Lavern Lammers 2. SEA Male 3.. DI►YE QF °DEATH (Mo., Day, Yr.) May 21,2015 - . 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH St. Paul, Nebraska 5a. AGE - Last Birthday (Yrs.) 69 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) December 18, 1945 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -64 -1067 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health Nebraska Heart 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 (Induce Gip Code) Lincoln 68526 i ou. ii' iJNT: JF DEATH Lancaster 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2415 N. Sherman Blvd 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 (First, Middle, Last, Suffix) If wife, give maiden name Rita Kaye Grossart 11. FATHER'S -NAME (First, Middle, Last, Suffix) LaVerne Lammers 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Shirley Studley 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Rita Kaye Lammers 14b. RELATIONSHIP TO DECEDENT Wife 16. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Katie M. Smydra 16b. LICENSE NO. 1454 16c. DATE (Mo., Day, Yr.) May 27, 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 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 18. 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, 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) Severe Metabolic Acidosis disease or condition resulting onset to death Hours In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Sepsis One Month any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter he UNDERLYING CAUSE c) Unknown (disease or injury that initiated - the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: l onset to death LAST d) 1 8. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Multiple Debridements Of Coccyx Decubitus, Recent Aspiration Pneumonia, Diabetes Mellitus. 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 ❑ 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 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE a W F 1 i 1 23 r)ATF rW DEATH (Mo. Dmr. Yr ) I May 21, 20'15 z G 1 24a. .2 g g ® E , E a. $ w Z o 0 a ~ c a U DATE SIGNED (Mo., Day. Yr) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) May 26, 2015 23c. TIME OF DEATH 01:20 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD u ' i O 3d. To the best of my knowledge, death'occurred at the time, date and place 2 G and due to the cause(s) stated. (Signature and Title) Janet L. Huenink, APRN 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? [] YES ❑ NO 0 PROBABLY El UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION ®YES ❑ NO BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES 0 N 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Janet L. Huenink, APRN, 7440 S 91st St, Lincoln, Nebraska, 68526 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) May 29, 2015 DATE OF ISSUANCE 06/02/2015 LINCOLN, NEBRASKA STATE OF NEBRASKA 201508087 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH, NO SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NkBRASKA psPA Tft4ENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FQ t'VIV4L R 'R �� e STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN'SEF1)410E9 CERTIFICATE OF DEATH `. STANLEY S. OJ PER ASSISTVIT1TALEREGIATRY1 .a 4PARTMENt CIF HEA,LTI{ ANC) }. Fitg1 SERVICES i "; «• 15 03101