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DATE OF ISSUANCE
<br />AUG 11 2015
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />201603194
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIQE9'
<br />CERTIFICATE OF DEATH
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL'T.t ANv VVMAPlf SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH„THE NEERASK4 Dt#4 TMLNT CJF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR if l`AL 14 CCRDS, •
<br />4 S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEP,AkTMFNT OF HEALTH AND
<br />HUMAAI SERVICES
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<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Dennis Alfred Shepherd
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ansley, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508 -50 -8248
<br />8b. FACILITY -NAME (if not Institution, give street and number)
<br />4120 Horseshoe Place
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />4120 Horseshoe Place
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />John Shepherd
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME
<br />(Yes, No, or Unk.) N Esther Shepher
<br />15. METHOD OF DISPOSITION
<br />al Burial ❑Donation
<br />Cremation ❑Entombment
<br />❑Removal ❑OtherfSpeeify)
<br />178. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />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,
<br />respiratory anent, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In death)
<br />APPROXIMATE INTERVAL
<br />Sequentially list conditions, If b)
<br />any, leading to the cause listed
<br />onset to death
<br />on line a.
<br />Enter the UNDERLYING CAUSE c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />onset to death
<br />(disease or Injury that initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />['Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑Unknown if pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
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<br />23d. To the best of my knowledge, death occurred at the time, date a nd place u W z O
<br />and due to the causes) tated.(Signature and Title) ,
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<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />28a. REGISTRAR'S SIGNATURE
<br />a) VII I { � � J7 G r o s - -- -
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />23c. TIME OF DEATH
<br />9b. COUNTY
<br />Hall
<br />22b. TIME OF INJURY
<br />m
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />72
<br />16a. EMB • _,t: - -SIGNATURE
<br />21a. MANNER OF DEATH
<br />lig..Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />&o A
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />HOURS
<br />85. PLACE OF DEATH
<br />HOSPITAL: ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER" ❑ Nursing Home /LTC ❑ Hospice Facility
<br />® Decedent's Home
<br />❑ Other(Specify)
<br />Ed. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY..,
<br />MINS.
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />100., Day, Yr.)
<br />December 24, 1942
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Esther Lopez
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Goldie Hurlburt
<br />16b. LICENSE NO.
<br />9g. INSIDE CITY LIMITS
<br />E Yes ❑ No
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife.
<br />16c. DATE
<br />July 28, 2010
<br />16d. CE ETERY, CREMATORY OR OTHEf2 LOCATION CITY/TOWN
<br />Gran, City Cemetery Grand Island
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />onset to death
<br />, ,r �-i. Reiel
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES X] NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES `.10
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />24b. TIME OF DEATH
<br />m
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />24e. On the basis of examination and /or Investigation, in my opinion death occurred
<br />at the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CON RIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />OYES �,� NO ❑ OB LY ❑ UNKNOWN ❑ YES 1F.„ NO
<br />27. NAME, TIT CLEAND ADDRESS OF CERTIFIER (Type or Print) '�-
<br />\.) A r Fr \/ �► V >< .ro 5.crou W. ,l-iz-t iW . 6- '=- N c . to 0 3----
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />AUG 3 2015
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO ❑ YES ❑ NO
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