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�llAte x a AV, Mies tatsh ,. ` 4 STATE OF NEBRASKA $4t. :. rte.,,, , yam., Lae 4NJ1Fho,..4 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 201606213 5/9/2016 DATE OF ISSUANCE LINCOLN, NEBRASKA 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE-STATE COUNTY Nebraska 19b. Hall 9d. STREET AND'NUMBER 404 E. Nebraska Ave 1#3a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married ❑Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Ferdinand W Spath 9c. CITY OR TOWN Grand Island 9e. APT. NO. 1Ob. NAME OF SPOUSE (First, Middle, Jacqueline Faye Whitt 13. EVER IN U.S.: ARMED FORCES? Give dates of service if Yes. 145. INFORMANT - NAME. (Yes, No, or link/ Yes )02/13/1946- 09/01/1947 Jacqueline Fa e S•ath 8d. COUNTY OF DEATH Hall 12. MOTHER'S -NAME (First, Middle, Frances Alta Schmidt 9f. ZIP CODE 9g. INSIDE CITY LIMITS'' 68801 I YES ❑ NO Last, Suffix) If wife, give maiden name Maiden Surname) 14b. RELATIONSHIP TO DECEDENT Wife 23b. DATE SIGNED (Mo., Day, Yr.) A.ril 22 2016 23c. TIME OF DEATH 08:55 PM 1. DECEDENTS-NAME (First, Middle, Last, Suffix) Rolland Fred Spath 4. CITY:AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Plainview, Nebraska 7. SOCIAL SECURITY NUMBER 506 -30 -3245 . FACILITY -NAME (If not Institution, give street and number) Grand Island Veterans Home 5. METHOD OF DISPOSITION ❑ Burial ❑ Donation E Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) AU Faiths Funeral Home. 2929 S. Locust Street. Grand Is:and, Nebraska IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting in death) .,,. S equentially list nGlltittiolta, if any, Ieiading W the cease listed:: on line Enter the UNDERLYING CAUSE disease Or injury. that initiated he eyeMs reeohingin death1 • LAST;: 22a. DATE OF INJURY (Mo., Day, Yr.) d. INJURY ATWORK7 .: ❑YES ❑NO 28a. R 23a. DATE OF DEATH (Mo., Day, Yr.) April 21. 2016 NATURE STATE OF NEBRASKA - DEPARTMENT OF HEALTH! AND HUMAN SERVICES CERTIFICATE OF DEATH 16a. EMBALMER- SIGNATURE Not Embalmed 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services DUE TO, OR AS A CONSEQUENCE OF: b)Alzheimers Disease DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 20.IFFEMALE: ❑ Not pregnant :withinpest year ❑ Pregnant at time of death ❑ Not pregnant, put pregnant within 42 days of death ❑Nut pregnant, but pregnant 43 days to 1 year before death ❑ ifnknewn if pregnant withiir the past year 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 3d. To the best of my knowledge, death occurred at the time date and place and due to the causelsl stated. (Signature and Title) pOUBIaS J. IVlorin, MD ........... ..... .......... ......... ........ 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could '. not be determined CITY/TOWN 5a, AGE - Last Birthday (Yrs.) 88 5 Q i b. UNDER 1 YEAR MOS. DAYS 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 16b. LICENSE NO. CAUSE OF DEATH (See instructions and examples) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES E NO ❑ PROBABLY ❑ UNKNOWN ❑ YES E NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Douglas J: Morin, MD, 2300 West Capital Avenue, Grand Island, Nebraska, 68803 STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 2. SEX Male Gibbon 5c. UNDER 1 DAY HOURS ate MINS. OTHER E Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) CITY/TOWN 16 02321 3. DATE OF DEATH (Mo., Day, Yr.) April21, 2016 6. DATE OF BIRTH (Mq.,Day, Yrr October 3, 1927! ❑ Hospice Facility 16c. DATE (Mo., Day, Yr.) April 23, 2016 STATE Nebraska 117b Zip Code . 08801 . PART I. Enter the chain Ofewints- - diseases, injuries, or complications -that directly caused the death.00 NOT enter terminal events such as cardiac arrest, reSpiratery arrest, or vemrleular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 21b. IF TRANSPORTATION INJURY DrlverlOperator ❑ Passenger 00 Pedestrian OtheriSpecify) STATE 24a. DATE SIGNED (Mo., Day, Yr.) APPROXTMATEINTERV onset to death 2 Days onset to death 10 Years onset to death onset to death' 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? DYES I Na 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH ?:. ❑ YES ❑ NO 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 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 28b. DATE FILED BY REGISTRAR( Day, Y April 26, 2016 0 NO