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��!� Ali rElf1' Migrr. 8 re w W U 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Douglas Lee Sloan 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 240 -78 -4066 FACILITY -NAME (If not institution, give street and number) WHEN ! nix 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 6/21/2016 LINCOLN, NEBRASKA CHi •(-)ealth •St. Fraicis Sc. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 217 East 22nd Street 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Lewis Sloan 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No or Unk.) Yes 'i 09/02/1969-08/31/1992 15. METHOD OF DISPOSITION El Burial ❑ Donation ❑ Cremation ❑ Entombment ❑::Removal <0 Other (Specify) 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel'Funeral Home. 1123 W. 2nd. Grand Island. Nebraska IMMEDIATE CAUSE (Final disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list nonemon it '.;) any, leading to the cause hated'' on 1i1ie a. Enter the UNDERLYING CAUSE (disease of injury:;that initiafad the enema rasuhieg in heath) LAST 20. IF: FEMALE: :' ❑ Not pregnanl within past year ❑ Pregnant at time of death ❑,; Not pregnant, but pregnant within 42 days of death ❑ No1 pregnant but pregnant t 43 days to 1 year before death ❑ Unknmm If pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 2d. INJURY AT WORTS? {]YES ❑ NO 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. U Z O E cl e fe 23 a. DATE C OF DEATH hqC.., Day, Yr.) Arne 12, .2016 Do Auld Wirth, MD 9b. COUNTY Hall 16a. EMBALMER-SIGNATURE Christopher J. Loecker DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH June 15 2016 07:17 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) STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 201604197 5a, AGE - Last Birthday (Yrs.) 66 14a. INFORMANT -NAME Lois L Sloan 21a. MANNER OF DEATH El Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide 0 not be detemened CITY /TOWN Nebrask b. UNDER 1 YEAR MOS. 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA 25, DID TOBACCO USE CO NTRIBUTE ICI THE DEATH? - 26a. HAS ORGAN OR 11SSUE s e AT( YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES fil NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Donald Wirth, MD, 2116 W Faidley #400, Box 9802, Grand Island 28a.; SIGNATURE DAYS 9c. CITY OR TOWN Grand Island' 9e. APT. NO. CAUSE OF DEATH (See instructions and examples) ,68803 16b. LICENSE NO. 1421 2. SEX Male 5c. UNDER 1 DAY HOURS 10b. NAME OF SPOUSE (Fir Lois L Feldt 12. MOTHER'S-NAME (First, Middle, Margaret Ashworth 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Grand Island City Cemetery Grand Island STATE 24a. DATE SIGNED (Mo., Day, Yr.) ce mvlo aa, z E Z O z O BEEN CONSIDERED? MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 3d. COUNTY OF DEATH Hall 9f. ZIP CODE 68801 Middle, Last, Suffix) If wife, give maiden name 18. PART 1. Enter tMecham of events-- diseases, injuries, or complications -that directly caused the death, DO NOT enter terminal events such as cardiac arrest, respiratory artele, of venteculai fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one Cause on a line, Add additional lines if necessary. IMMEDIATE CAUSE: a)Acute Myocardial Infarction 21b. IF TRANSPORTATION INJURY ❑ neverIOperator ❑ Passenger 0 Pedestrian Other(Spec atom Maiden Surname) 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given In PART I. Pneumonia December 12 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify): 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 cause(s) stated. (Signature and Tale) 26b. WAS CONSENT GRAN Not Applicable if 26a Is NO 28b. DATE FILED BY REGISTRA June 15, 2016 3. DATE OF DEATH (Mo., Day, Yr.) June 12, 2016 6. DATE OF BIRTH (Mo., Day, Yr.), ❑ Hospice Facility 9g. INSIDE CITY LIMIT ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo„ Day, Yr.) June 16, 2016 STATE Nebraska 171 Zip Code 68801 APPROXIMATE INTERVAL onsetto,deat One Day 949 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? DYES ® NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑YES 0 N (Mo. Day, Y ZIP CODE �D7 ❑YES ❑ NO