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18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CON TED? ❑ YES NO 20. IF FEMALE: ❑Not pregnant within past year 0 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 pregnant within the past year 21a. MANNER OF DEATH peacural ❑ Homicide ❑ Accident ❑ Pending investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY P RMED? ❑ YES O 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? D YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES 110 22e. DESCRIBE HOW INJURY OCCURRED STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 354869 re W LL Ui W '0 at N a O U a, to F 1. DECEDENTS -NAME (First, Gerald Ray Kindig Middle, Last, Suffix) 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 505 -54 -4114 lib. FACILITY -NAME (N not Institution, give street and number) Nebraska Medical Center - University P 8c. CITY OR TOWN OF DEATH (include Zip Code) Omaha 68198 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 1310 Branding Iron Lane 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married• but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First Middle, Last, Suffix) Clyde B Kindig 13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes. (Yes, No, or Unit) Yes 02/27/1967- 03/07/1972 15. METHOD OF DISPOSITION ®Buda) ❑Donation ['Cremation ['Entombment ❑Removal ❑oberispeciftd 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 1 CAUSE OF DEATH (See instructions and examples) 1e. PART 1. Enter the sat r Meese . diseases, Injuries, or complications -Nat directly caused the death. 00 NOT enter terminal events such as cardiac amst respiratory amp, or ventricularabrillation without showing the etiology. DO NOT ABBREVIAT5. Enter only one cause on a Ilne. Add additional lines If necessary. IMMEDIATE CAUSE (Final disease or condition resulting In death) IMMEDIATE CAUSE: a) r7 l l L t r � APPROXIMATE INTERVAL onset to death 5 1 Sequentially list conditions, if any, leading to the cause listed on Ilne a. DUE TO,Q b) v` /R AS A C OF:, 0 .-...1 2 onset to dr ` h Ord n• r Enter the UNDERLYING CAUSE ( disease or Injury that Initi the events resulting In death) DUE TO, OR AS A COC)r 0E: onset to dej ......4 I LAST d) 22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. 26. DID TOBACCVIE CONTRIBUTE TO THE DEATH? ❑ YES NO ❑ PROBABLY ❑ UNKNOWN 27. NA ME, TILE e A S 0 p E CI , 10 r" to 20a. REGISTRAR'S SIONATU /h 5a. AGE -Last Birthday (Yrs.) 67 Sb. COUNTY Hall 10b. NAME OF SPOUSE (First. Middle, Last, SufBxt N wife, give maiden name. Patricia Baasch 14a. INFORMANT -NAME Patricia Kindig 18a. EMBAL NATURE 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN Grand Island City Cemetery Grand Island STATE Nebraska DUE TO, OR AS A CONSEQUENCE OF: CITY/TOWN re a 1Z rc , E� z S e g o a0 N CI 23a.O OF �T o., Qay, Yr.) ) 23b. q / / Dm, Yr.) 23c. TIME - pm 23d. To the best • - • - ath occurred at the time, date and place and • • the cause(s) stated. ( Igna are and Title) 5b. UNDER 1 YEAR MOS. DAYS 9e. APT. NO. 2. SEX Mate 5e. UNDER 1 DAY HOURS Ba. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/Outpatient ❑ DOA OTHER: ❑ Nursing Home/LTC ❑ Hospice Facility ❑ Decedent's Home ❑ othedSpecl y ) 9c. CITY OR TOWN Grand Island 12. MOTHER'S -NAME (First Middle, Maiden Surname) Faith B Carter 18b. LICENSE NO. Zr?/ 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) A. MINS. 3. DATE OF DEATH (Mo.,Day,Yr.) April 18, 2014 8. DATE OF BIRTH (Mo., Day, Yrl February 8, 1947 8d. COUNTY OF DEATH Douglas 9f. BP CODE 68803 STATE 9g. INSIDE CITY LIMITS ® Yes ❑ No 14b. RELATIONSHIP TO DECEDENT Spouse 18e. DATE (Mo., Day, Yr.) April 23, 2014 onset to death 17b. Zip Code 68801 ZIP CODE 24b. TIME OF DEATH m 24d. TIME PRONOUNCED DEAD m 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 H 26a is NO ❑ YES ❑ NO 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES B / NO f■Prts K44.1 CQA : QQ-1*4 yN 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) MAY 28 7.414 This certifies this document to be a true copy of an original record on file with Vital Statistics, Douglas County Health Dept., Omaha, Nebraska. Certified copies must have a raised seal in the area to the left. Reproduction of this green certificate are not legal copies. Date Issued: ,APR f 2014 Registrar � CIL a Cote