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iitaddikrabiu, t u.t Asa. / , . 4, !N Iv X 61 ## ➢ , CTATC 1% AICQDACIICA �P "t ..If tx I,# �¢k..fi.ez. ;y 4. 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 04/18/2016 LINCOLN, NEBRASKA 24a. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 06:38 PM earl D DEAD 1. DECEDENTS - NAME (First, Middle, Last, Suffix) Berniece Lois Dixon 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Creighton, Nebraska 7. SOCIAL SECURITY NUMBER 508 - -2063 8b. FACILITY -NAME (If not Institution, give street and number) t4 fl Park Place A Golden Living Center W 8c. CITY OR TOWN OF DEATH (Include Zip Code) tY o Grand Island 68803 9a. RESIDENCE -STATE Nebraska LL 9d. STREET AND NUMBER 118 S. Ingalls St. 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married • ❑ Married, but separated? ® Widowed ❑ Divorced ❑ Unknown 1. FATHER'S -NAME (First, Middle, Last, Suffix) Levi Jensen E 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, Or Urtk.) NO S 15. METHOD OF DISPOSITION O ❑ Burial ❑ Donation 0 Cremation ❑ Entombment ❑ Removal <❑ other {specif IMMEDIATE CAUSE (Final disease or condition resulting ill death) Sequentially list eonddians, if any, leadingtd the cause listed on line a. Enter the UNDERLYING CAUSE ldiseeeel er Injury that initiated. the events renelnny in dea0) LAST r _. IMMEDIATE CAUSE: a) Pneumonia DUE TO, OR AS A CONSEQUENCE OF: b)Chrorlic Obstructive Pulmonary Disease DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 20. IF :FEMALE: s ❑ Not pregnantwithm past year ❑ Pregnant at time of death ❑ Not pregnant,. tut pregnant within 42 days of death Not preghan ;, #ut preg 43 days to 1 year before death 0 Unknown if p egnam withier the past year W (2 1 :m • 22a. DATE OF INJURY (Mo., Day, Yr.) 0 0 2d..INJURY ATtnrORK? D DNO 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. 3a. DATE OF DEATH (Mo., Day, Yr.) Aped 4 201.6 Ib, DATE SI4Nt3D Mo., Day, Yr.) Aril 8, 2016 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 29d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Travis S. Hageman,'MD 5a. AGE - Last Birthday (Yrs.) 99 9b. COUNTY Hall STRAESSIGNATURE 5b. UNDER 1 YEAR MOS, DAYS 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand 'island 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. OTHER ® Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 9e. APT. NO. 9f. ZIP CODE 68803 10b. NAME OF, SPOUSE (First, Middle, Last Suffix) If wife, give maiden name W Clay Dixon 1 12. MOTHER'S -NAME (First, Middle, Maiden Sumame) Dora Brokaw 14a. INFORMANT -NAME Gene Raymond Scarbrough 16a. EMBALMER - SIGNATURE Not Embalmed 16b. LICENSE NO. 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon July 12, 1916 17a. FUNERAL }TOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island,' Nebraska CAUSE OF DEATH (See instructions and examples) . PART I. Enter tle:fhaih of events -- diseases, injuries, or complications -that directly caused the death, DO: NOT enter terminal events such as cardiac arrest, respiratory arr5St, er ventrinular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Cardiornyopathy 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could net be determined CITY/TOWN 25. DID TOBACCO UEE CONTRIBUTE TO THE DEATH? ❑ YES Et NO ❑PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES ID NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger 0 Pedestrian 0 Other(Specify) 24c. PRONOUNCED DEAD (Mo., Day, Yr. STATE 3. DATE OF DEATH (Mo., Day, Yr.) April 4, 2016 6. DATE OF BIRTH (Mo., Day, Yr,). 14b. RELATIONSHIP TO DECEDENT Son 16c. DATE (Mo., Day, Yr:) April 7, 2016 AP P ROXIMATE`I NTERI/AL. onset to death Days onset to:dee Years onset to death onset ❑ Hospice Facility 9g. INSIDE CITY LIMITS YES ❑ NO STATE Nebraska 17b, Zip Code 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 0 N 21c. WAS AN AUTOPSY PERFORATED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? ❑YES 0 N 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24d. TIME PRONOUN 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 Tine) 26b. WAS CONSENT GRANTED? ' Not Applicable if 26a is NO ❑ YES' ❑ NO 28b. DATE FILED BY REGISTRAR (Mo „ ,Day, Yr.) April 12, 2016 201602738 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. C OOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES