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To be completed /verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Gaylord Lee Peterson 2. SEX ,4 ' Male : 3, DATE OF DEATH (Mo., Day, Yr.) ' December 23, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Bradish, Nebraska 5a. AGE - Last Birthday (Yrs.) 79 5b. UNDER 1 YEAR 5c. UNDER 1 DAY ' 6 DATE OF BIRTH (Mo., Day, Yr.) April 15, 1936 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -40 -7628 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8a. PLACE OF DEATH HOSPITAL ® Inpatient gTHER ❑ Nursing Home/LTC ❑ Hospice Facility 0 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 1 9c. Hail CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2416 N. Hancock Avenue 9e. APT, NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH 0 Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Beverly A Milliken 11. FATHER'S -NAME (First, Middle, Last, Suffix) Clarence Peterson 12. MOTHER'S -NAME (First, Middle, Maiden Sumeme) Violet Nelson 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Beverly A Peterson 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.) December 24, 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) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER I 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, ' 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) Cancer Of Pancreas disease or condition resulting onset to death 2 Years in death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death Sequentially list conditions, If b) Diabetes 1 10 Years any, leading to the cause listed 1 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: i 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) I 1 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death ` u _ not resulting in the underlying cause given in PART I. Pulmonary Embolus 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 0. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 clays 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 ❑ Pe Investigation ❑ suicide ❑ Could not be 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? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 122b. 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 S NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE CERTIFIER NUJ 23a. DATE OF DEATH (Mo., Day, Yr.) December 23, 2015 mpleted by i PHYSICIAN Y ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) December 24, 2015 23c. TIME OF DEATH 04:02 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Gary Settje, MD 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and plane and due to the cause(s) stated. (Signature and Tide) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Gary Settje, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 a 128a. REGISTRAR'S SIGNATURE A i � � 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 28, 2015 STATE OF NEBRASKA 201600584 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 NEBRASKA"D€PARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL IRE! QI DS: DATE OF ISSUANCE 12/31/2015 LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH StNLEY S., f OOPER .< • A8S(STANT STATE- REGI.TRAR1 DEPART19 , "T L �;O D; FHEALTH;41 HU /S V1CCS '' . • _ ` 15 07467