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STATE OF NEBRASKA miatri r f , ?. 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 04/12/2016 LINCOLN NEBRASKA STAN S. OOPER 2 016 0 3 016 ASS S ANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH A ate 1. DECEDENT'S - NAME (First, Middle, Last, Suffix) Alfred Emil Nabity 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Chapman, Nebraska 7. SOCIAL SECURITY NUMBER 507 -42 -4520 lib. FACILITY -NAME (If not Institution, give street and number) ce • Good Sam. Society- Hastings Village, Perkins Pay. W 8c. CITY OR TOWN OF DEATH (Include Zip Code) tY J re re LL 'C a) 9a. RESIDENCE-STATE Nebraska • 9d. STREET AND NUMBER 1730 S. Gretchen Avenue 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑:Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Joseph Nabity 13. EVER U.S., ARMED, FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 04/12/1951- 03/21 /1953 p S. METHOD OF DISPOSITION Fd- Ej `Burial 0 Donation ❑ Cremation ❑ Entombment 0 Removal ;:,❑ Other (Specify) Hastings 68902 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska CAUSE OF DEATH (See instructions and examples) t$. PART 1. Enter thechaln of events -- 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 fine. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Rectal Cancer disease or condition resulting APPROXIMATE IN TERVAL onset to death 1 Year DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions if I<'. b) any, (eedm ca g to the.uan l on line a. onset to death Enter the UNDERLYING CAUSE c ) 1tliseasq or injury tbat imhateq . the events resulting In death) LAST DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 20. IF :FEMALE: fm 0 Not pregnant within past year W • ❑ Pregnant at time of death I 0 Not pregnant,:but pregnant within 42 days of death ❑ flat pregnapt „but pregnarn 63 days to 1 year before death ❑ Unknown d pregnam within the past year E • 22a. DATE OF INJURY (Mo., Day, Yr.) 0 V d 0 22d.: INJURT AT WORK?„ DYES ONO 22b. TIME OF INJURY 5a, AGE - Last Birthday (Yrs.) 86 9b. COUNTY Hall lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden n Beata Ann Dubas 16a. EMBALMER- SIGNATURE Katie M. Smydra 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Cemetery 14a. INFORMANT -NAME Beata Ann Nabity, 21a. MANNER OF DEATH ® Natural 0 Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide 0 Could not be determined .5 F E `Z S ¢ Q 23a. DATE OF DEATH (Mo., Day, Yr.) April 5, 2015 2Sb. DATE SIGNED (Mo., Day, Yr.) April 6, 2016 23c. TIME OF DEATH 08:42 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) Pau)..Wibbels, MD Sb. UNDER 1 YEAR MOS. DAYS 8a. PLACE OF DEATH HOSPITAL OInpatient ER/outpatient ❑ DOA HOURS 9e. APT. NO. 6b. LICENSE NO. 1454 CITY / TOWN Grand Island 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ Pedestrian Other (Specify) 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) -- 22e. DESCRIBE HOW INJURY OCCURRED 24a. DATE SIGNED (Mo., Day, Yr.) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? D YES kJ NO ❑ PROBABLY 0 UNKNOWN ® YES ❑ NO 2$a. REGISTRAR'S SIGNATURE 2. SEX Male 5c. UNDER 1 DAY MINS. OTHER ® Nursing Home /LTC ❑ Hospice Facility 0 Decedent's Home ❑ Other (Specify) ad. COUNTY OF DEATH Adams 9c. CITY OR TOWN Grand Island 9f. ZIP CODE 68803 3. DATE OF DEATH (Mo., Day, Yr.) April 5, 2016 6. DATE OF BIRTH (M January 8, 1930 Day, Yr.) 9g. INSIDE CITY LIMITS M YES ❑ NO 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Wilhelmina Trubl 14b. RELATIONSHIP TO DEC. EDENT Wife 16c. DATE (Mo., Day, Yr.) April 9, 2016 STATE Nebraska 176, Zip Code 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 21 NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILA81_E TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 24b. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 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 cau e(s) stated. (Signature and TitleI 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES" EI NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Paul Wibbels, MD, 2115 N Kansas Avenue, Hastings, Nebraska, 68901 28b. DATE FILED BY REGISTRAR (Md., Day, Yr.) April 7, 2016