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l tiltY ^ V, STATE OF NEBRASKA o , 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 6/6/2016 LINCOLN, NEBRASKA 2016059 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH ao STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Robert Willard Long 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Norfolk, Nebraska 7. SOCIAL SECURITY NUMBER 507.40 -7332 8b: FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9d. STREET AND NUMBER 20 Via Trivoli 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated:; ❑ Widowed ❑ Divorced ❑ Unknown 5s, AGE - 4ast Birthday (Yrs.) 80 11. FATHER'S -NAME (First, Middle, Last, Suffix) Willard Lonq 13, EVER IN U.S. ARMED. FORCES? Give dates of service if Yes. (Yes, No, or Ufll.)Yes "01/13/1955- 01/11/1957 16a. EMBALMER - SIGNATURE sit' 15. METHOD OF DISPOSITION IS ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal <❑ Other : Not Embalmed 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY 1 TOWN Central Nebraska Cremation Services Gibbon STATE Nebraska 7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska 14a. INFORMANT -NAME Phyllis Kathervne Lonq CAUSE OF DEATH (See instructions and examples) 18. PART 1. Enter die Chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter tenninal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: a) Idiopathic Pulmonary Fibrosis IMMEDIATE CAUSE (Final disease or condition resulting in death) APPROXIMATE INTERVAL onset to death' 5 Years DUE TO, OR AS A CONSEQUENCE OF: seque*maay est cpfdhione, d f: b) any, leading fo the cause listed s7 online a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (diseaseot injury that initiated nta resulting in death) the eve LAST` 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. Coronary Artery Disease, Chronic Kidney Disease, Diabetes 11, 20. IP`FEMALE: ❑ Net pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant : but preprilun 43 days to 1 year before death ❑ unknovm'd pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d ; INJURY AT WORK? ❑ YES NO 22f. LOCATION' OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE u z Z3a. DATE OF:DEATH (Mo., Day, Yr.) May 27, 2016 23b. DATE SIGNED (Mo., Day, Yr.) May 31, 2016 22b. TIME OF INJURY 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Couldnot be determined 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site etc Specify) 22e. DESCRIBE HOW INJURY OCCURRED 23c. TIME OF DEATH 11:09 AM 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES NO 0 PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Gary Sett*, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 388, REGISTRAR S SIGNATURE j a - / acyj 5b. UNDER 1 YEAR 8a. PLACE OF DEATH HOSPITAL E Inpatient ERlOutpatient ❑ DOA OTHER ❑ Nursing Home/LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 9c. CITY OR TOWN Grand Island! DAYS HOURS 8d. COUNTY OF DEATH Hall 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY MINS. 9f. ZIP CODE 68803 10b, NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Phyllis Ka lervne 'Kruse'; 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Cathryne Shannon 16b. LICENSE NO. 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES VINO • 3. DATE OF DEATH (Mo., Day, Yr.1 May 27, 2016 6. DATE OF BIRTH (Mo., Day, Yr. March 18, 1936 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) June 2, 2016 17b. Zip Code 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 6sJ ;NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ENO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES 0 N 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD u < O 3d, To the best of my knowledge, death occurred at the time, date and place .8 c and due to the causes) stated. (Signature and Tttle) i;; Gary Settje, MD 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 ❑ YES Q NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) June 1,2016