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xc».1 s. STATE OF NEBRASKA RItt;:a71 :1 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 9/6/2016 LINCOLN, NEBRASKA 201606199 STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENTS -NAME (First, Middle, Last, Suffix) John Milton Bowling Jr PART F. Enter the: chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, reepiratory errant, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting APPROXIMATE INTERVAL: onset to death 1 Day ITV AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Independence, Missouri 7. SOCIAL SECURITY NUMBER 547 -60 -5663 8b. FACILITY -NAME (If not Institution, give street and number) 0 cs Good Sam. Society - Hastings Village, Perkins Pay. K 8c. CITY OR TOWN OF DEATH (Include Zip Code) o Hastings 68902 9a RESIDENCE -STATE z Nebraska LL 9d. STREET AND > NUMBER ' • 348 Redwood Road St 1Qa. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married ❑ Married, but Separated;, ❑ Widowed ❑ Divorced ❑ Unknown ▪ 11. FATHER'S -NAME (First,' Middle, Last, Suffix) S John Milton Bowling Sr 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Kathleen Reynolds £ 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. a (Yes, No, or unk.) Yes 05/31/1962-02/01/1972 15. METHQO OF DtSPQSITION H ❑ Burial 0 Donation E Cremation ❑ Entombment ❑ Removal : ❑ Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston- Sondermann Funeral Home. 601 N. Webb Road. Grand Island, Nebraska i 17b. Zip Code 68803 CAUSE OF DEATH (See instructions and examples) in death)..... Sequentially Bat oonditiottS. if any, leading to the cause fisted on line DUE TO, OR AS A CONSEQUENCE OF: b) Stroke onset to death .: 2 Wee4 DUE TO, OR AS A CONSEQUENCE OF: c) onset to death Enter the UNDERLYING CAUSE ; (diseageorinjury;that inidatep. rasgatng:ln deatI1 16a. EMBALMER- SIGNATURE Not Embalmed 5a. AGE - Last Birthday (Yrs.) 9b. COUNTY Hall lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Carol Ann ` Bowling 14a. INFORMANT-NAME Carol Bowling 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Crematory CITY / TOWN Grand Island STATE Nebraska the events LAST :< DUE TO, OR AS A CONSEQUENCE OF: 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting In the underlying cause given In PART I. 0. 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 pregnant within the past year m E 22a. DATE OF INJURY (Mo., Day, Yr.) m 0 2's INJURY AT WORK? []YiS ❑N4 234: DATE OF DEATH (Mo., Day, Yr.) August 20, 2016 234. DATE SIGNED (Mo., Day, Yr.) Au`u ust 22 2016 22b. TIME OF INJURY 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Titte) Paul.Wibbe(s; MD . .............. ............ . ........................... 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? YES ] NO ❑ PROBABLY ❑ UNKNOWN 28a. REGIZxTRAR'S SIGNATURE 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation 0 Suicide ❑ Could, not be determined 230. TIME OF DEATH 09:26 PM 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑'IER/Outpatient ©DOA OTHER E Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 90. CITY. OR TOWN Grand Island 5b. UNDER 1 YEAR MOS. DAYS HOURS 8d. COUNTY OF DEATH Adams 9e. APT. NO. 16b. LICENSE NO. 21b.IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) . PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN: CONSIDERED? E YES NO 2. SEX Male 5c. UNDER 1 DAY MINS. 9f. ZIP CODE 68803 3. DATE OF DEATH (Mo., Day, W.) August 20, 2016 6. DATE OF BIRTH (Mo., Day, Yr.) August 29, 1944!` 9g. INSIDE CITY LIMITS E YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day,Yr.) August 22, 2016 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? DYES E NO 21c. WAS AN AUTOPSY PeRFO ❑ YES E NO ED? 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? .. ❑ YES 0 N 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREETS. NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE:, • 24b. TIME OF DEATH 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: Y 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 into., Liay, Yc} August 30, 2016 1