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it& or ; WY; ,... . 1 u J . _. ∎ ∎irks/ eakteR AA. t o rtiz :TATE OF NEBRASKA libtxwe At fi WHEN > THIS ' COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 02/23/2016 LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH A cafe STANLEY S. OPER 201601Z72 ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES .a. 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Floyd Sidney White 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 505-16-1220 Sb. FACILITY -NAME (If not Institution, give street and number) Tiffany Square Care Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCESTATE Nebraska 9d. STREET AND NUMBER 24 St. James Place 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated ❑ Widowed ® Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Maiden Surname) Floyd White Anna Rasmussen 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or urik.) Yes i' 09/01/1943-12/20/1945 15. METHOD OF DISPOSITION ❑ Burial 0 Donation ® Cremation ❑ Entombment ❑, Removal < Other (Specify) 5a, AGE - Last Birthday (Yrs.) 96 9b. COUNTY Hall 5b. UNDER 1 YEAR MOS. DAYS 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 16a. EMBALMER- SIGNATURE Not Embalmed 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. OTHER ® Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) January 18, 1 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 9f. ZIP CODE 68803 lob. NAME OF. SPOUSE (First Middle, Last Suffix) If wife, give maiden name 14a. INFORMANT-NAME James White 16b. LICENSE NO. 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE Ne 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska CAUSE OF DEATH_ (See Instructions and examples) Ia' PART I Enter the chain of ettents =- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, 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) Cardiac Arrest disease or condition resulting A P P ROXIM A TI' INTERVAL in death) sequentially list coildihons, if any, leading to the cause fisted DUE TO, OR AS A CONSEQUENCE OF: b)Coronary Ischemia onset to death 7 Days onset to death 60 Years on line a. -- DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Atherosclerosis (disease or Injury :that initiated the events reswting I death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Macular Degeneration 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 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY ATWORK? YES ❑ NO 22b. TIME OF INJURY 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 23a. DATE OF DEATH (Mo., Day, Yr.) February 14, 2016 23b. DATE SIGNED (Mo., Day, Yr.) February 17, 2016 23c. TIME OF DEATH 10:55 PM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) arry L. Hansen, MD 21b, IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger 0 Pedestrian 0 Other (Specify) 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP cope 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? DYES 0 NO 28a. REGISTRAR'S SIGNATURE 3. DATE OF DEATH (Mo., Day, Yr.) February 14, 2016 6. DATE OF BIRTH (Mo., Day, Yr) 920 0 Hospice Facility 99. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Son 16c. DATE (Mo., Day, Yr.) February 17, 2016 17b, Zip Code 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? [] YES ® 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the tassels) stated. ISignature and Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Larry L. Hansen, MD, 3016 West Faidley, Grand Island, Nebraska, 68803 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) !; February 19, 2016