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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 L21 4T I ?1I9LrECORDS DATE OF ISSUANCE 12/23/2016 LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH A afottA STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1," y , � .. EBRA 1, PT.FatItow.TRI.-,07? mots . , tf. r Y J P �. .tu UJ re W U O O N 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Larry Wayne Gregg 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Hastings, Nebraska 7. SOCIAL SECURITY NUMBER 505 -56 -5725 84. FACILITY - NAME (if not Institution, give street and number) Saint Francis Medical Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68 9a. RESIDENCE.STATE Nebraska 9d. STREET AND NUMBER 316 E. Plum St 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, tint separated! ❑ Widowed ❑ Divorced ❑ Unknown 11. FATItER'S -NAME (First, Middle, Last, Suffix) Lawrence Grego 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No or Unk.) No 15. METHOD OF<DisF0smoN ❑Burial ❑ Donation ® Cremation ❑ Entombment ❑'Removal I❑ Other (Specify) 17a. FUNERAL NOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street, Grand Island. Nebraska CAUSE OF DEATH (See instructions and examples) 1e. PART 1. Enter the Chain Otevents -- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal 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 it necessary. IMMEDIATE CAUSE: :a1MEDIATE CAUSEirivai a) Myocardial Infarction disease or condition resulting APPROXIMATE INTERVAL onset to death <1 Day in death) .:.. Sequentially Est cdnditlons, if ;s any, leading to Me cause listed on line a DUE TO, OR AS A CONSEQUENCE OF: b) Coronary Artery Disease onset tO death > 1 MOntIl Enter the UNDERLYING CAUSE A 050464.0 fliur)t:14t intFiat4A:. DUE TO, OR AS A CONSEQUENCE OF: c) onset to death the events rasu h&tg an 4eath) LAST: DUE TO, OR AS A CONSEQUENCE OF: d) onset fo death 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Diabetes, Hypertension 20. IF`FEMALe: ❑ Not pregnant!whhin past. year ❑ Pregnant at time of death ❑ Not pregnant;;but pregnant within 42 days of death ❑ Not plegnam, but pregnant 43 days to 1 year before death ❑ Unknown lr pfegnaptwithin the past year 22a. DATE OF INJURY (Mo., Day, Yr.) d. INJURY AT:WORK? OYES ❑ NO 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 23s. DATE OF DEATH (Mo., Day, Yr ) $ Ma rch 27, 2014 4 2 3b DATE StGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 1 z March 29, 2014 10:27 AM o a O 3d. To the best of my knowledge, death occurred at the time, date and place 2 C and due to the cause(s) stated. (Signature and Title) o J Brown, L . rrown, MD 25. DM TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES II NO ❑ PROBABLY ❑ UNKNOWN ❑ YES EI NO 27. AME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Jennifer L:: Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 1 28a. REGISTRAR'S SIGNATURE 5a. AGE • Last Birthday (Yrs.) 72 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Katie M. Ewald 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide 0 Could not ba determined 5b. UNDER 1 YEAR MOS. DAYS HOURS 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY 14a. INFORMANT - NAME Karen Kay Greqq 16b. LICENSE NO. 1454 Vb. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) 24a. DATE SIGNED (Mo.. Day, Yr.) MINS. 9f. ZIP CODE 68832 3. DATE OF DEATH (Mo., Day, Yr.) March 27, 2014 6. DATE OF BIRTH (Mo., Day, Yr,) September 29, 1941 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ® ER/Outpatient DOA OTHER ❑ Nursing Home/LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Doniphan 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Karen Kay Schwieger 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Clara Hinrickus 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Md., Day, Yr.) March 31, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon STATE Nebraska 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 1 NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSEOF DEATH? ❑YES 0 N 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. )I 24d. TIME PRONOUNCED <D 9g. INSIDE CITY LIMITS ® YES ❑ NO 17b. Zip Code 68801 244. 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 Tide) 26b. WAS CONSENT GRANT Not Applicable if 26a is NO ❑ 'YES 28b. DATE FILED BY REGISTRAR (M April 2, 2014 D: