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STATE OF NEBRASKA v. ce Ei ui z u. LL a ) 7- 4) tb Q. c 2 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 6/10/2016 LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Douglas Dale Thompson 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 505 -62 -4263 St, FACILITY -NAME (If not Institution, give street and number) Wedgewood Care Center 8c. CITY CR TOWN OF DEATH (inciUde Zip :: Ada) Grand Island 68803 9a. RESIDENCE-STATE 9b. COUNTY Nebraska Hall 9d. STREET AND NUMBER 2891 South Nebraska Hwy 11 1Oa. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 1. FATHER'S•NANIE (First, Middle, Last, Suffix) Robert Thompson 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Ni 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfei Funeral Home. 1123 W. 2nd. Grand Island, Nebraska 16. PAItT L Enter the <;hai of eve rts respiratory arre$t, IMMEDIATE CAUSE (Final disease or condition resulting In death) Seque4,trally list conditions, if any, leading to the cause listed on tins'. a. Enter the UNDERLYING CAUSE (disease. or injury : that initiated the events reSuning in tleathJ ° :. :_, DUE TO, OR AS A CONSEQUENCE OF: LAS T !:: _... 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;Heimaa( within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 2d, INJURY AT WORK ? ❑YES .: 0 NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. d) 23a. DATE OF DEATH (Mo., Day, Yr.) June 3, 2016 STATE OF NEBRASKA - DEPARTMENT OF H CERTIFICATE 0 16a. EMBALMER - SIGNATURE Christopher J. Loecker Cameron Cemetery DUE TO, OR AS A CONSEQUENCE OF: b)Aspiration Pneumonia DUE TO, OR AS A CONSEQUENCE OF: c) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 23 b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH June 9, 2016 07:40 AM 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) Chad Vieth, MD 28a.;:REGISTRAR'S SIGNATURE 2016042 5a. AGE - Last Birthday (Yrs.) 14a. INFORMANT -NAME Dianne Thompson' 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22c. PLACE OF INJU CITYITOWN 6& 88. PLACE OF DEATH HOSPITAL 0 Inpatient ❑ ER/OUtpatient ❑ DOA 9c. CITY OR TOWN Wood River DID 25. 1D TOBACCO USE CONTRIBUTE TO THE DEATH? YES ❑ NO . ❑ PROBABLY ❑ UNKNOWN ❑ YES Ea NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand island, Nebraska, 68803 STANLEY S. COOPER Yv ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES EALTH AND HUMAN SERVICES F DEATH UNDER 1 YEAR AYS ed. COUNTY OF DFATH Hall 9e. APT. NO. 2. SEX Male HOURS 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Dianne Luth 12. MOTHER'S-NAME (First, Middle, Florence Becker 16b. LICENSE NO. 1421 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Wood River CAUSE OF DEATH (See instructions and examples) -- diseases, injuries, or complications -that directly caused the death, DO NOT enter terminal events such as cardiac arrest, ilar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter . only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: a) Multi System Organ Failure 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21b, IF TRANSPORTATION INJURY 0 Driver/Operator ❑ Passenger ❑ Pedestrian Other (Specify) STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr. 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? Sc. UNDER 1 DAY MINS. 9f. ZIP CODE 68883 OTHER El Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 3. DATE OF DEATH - ( June 3, 2016 January 4, 1948 Maiden Surname) 24b. TIME OF DEATH 6. DATE OF BIRTH (Mo., Day, Yr.) ❑ Hospice Facility 9g. INSIDE CITY LIMITS ❑ YES ® NO 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr.) June 9, 2016 STATE Nebraska 17b, Zip Code 68801 APPROXIMATE INTERVAL onset to death' Days onset to death Days onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES Ea NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO 21d, WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE QF DEATH? ❑ YES ❑ NO Y -At home, farm, street, factory, office building, construction site, etc, (Specify) ZIP 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 cause(s) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr,) June 9, 2016