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.0/4 vv v l" ) /eirlekteliks . A.0 . . 'i u LV 4. 0. STATE OF NEBRASKA l eff 5 i 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Billy Henry Thompson 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 7. SOCIAL SECURITY NUMBER 505 -54 -3177 fib. FACILITY -NAME (if not Institution, give street and number) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 RESIDENCE *STATE Nebraska 9d. STREET AND NUMBER 4119 W Airport Road 0 a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) William Henry Thompson 3. EVER IN U.S:: ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 5. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment Removal :❑ Other (Specify) Sequentially list cohdittons, if b) any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease of tnjuly Mat initiated the events resulting in dearer DUE TO, OR AS A CONSEQUENCE OF: LAST:: E,. d) 18. PART 11. OTHER 0. IF FEMALE: ❑ Not pregnant >althin pastyear ❑ P regnant at time of death ❑ Not pregeanl. but pregnant within 42 days of death ❑ Not pregnant, but ptegnant days to 1 year before death • ❑ t /itknewn if pregnant wittun the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d,<INJURY ATWORK? • ❑ YES . ❑ Nf� • 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. WHEN THIS li' 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 1/25/2017 LINCOLN, NEBRASKA Grand Island, Nebraska CH( Health St. Francis 23a. DATE OF DEATH (Mo., Day, Yr.) January 13 2017 23b. DATE SIGNED (Mo., Day, Yr.) January 18, 2017 Sara Graybitl,;MD STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 9b. COUNTY Hall 16a. EMBALMER-SIGNATURE Katie M. Smvdra 25. DIO TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES NO ❑ PROBABLY ❑ UNKNOWN 20170069,E Grand Island City Cemetery a) Cervical Spine Tumor - Unknown If Malignant DUE TO, OR AS A CONSEQUENCE OF: C) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 23c. TIME OF DEATH 07:55 AM Tc the best of my knowledge, death -ccurred ai the ' date ar n ulcer. and due to the cause(s) stated. (Signature and Title) 58. AGE - Last Birthday 5b. UNDER 1 YEAR 71 MOS 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand! Island 'Mb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name:. Delores Irene Minor 14a. INFORMANT -NAME Delores Irene Thompson< 1 12. MOTHER'S-NAME (First, Middle, Maiden Surname) Leona Buchanan Nohel 16d. CEMETERY, CREMATORY OR OTHER LOCATION 7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska CITY /TOWN 21a. MANNER OF DEATH ® Natural ❑ Homicide 0 Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined E 9 p O S 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Sara Graybill, MO, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 Coe/Pr"- DAYS STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 9e. APT. NO. 2. SEX Male 1 16b. LICENSE NO. 1454 5c. UNDER 1 DAY HOURS OTHER ❑ Nursing Home /LTC 0 Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall CITY / TOWN Grand Island CAUSE OF DEATH (See instructions and examples) MINS. 9f. ZIP CODE 68803 lit. PART I. Enter the chain of events- -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 if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final disease or condition resulting in death! DUE TO, OR AS A CONSEQUENCE OF: IGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger 0 Pedestrian 0 Other (Specify) STATE 24a. DATE SIGNED (Mo., Day, Yr.) c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN DR TISSUE DONATION BEEN CONSIDERED? ❑ YES El NO 6. DATE OF BIRTH (Mo., Day, Yr.) 3. DATE OF DEATH (Mo., Day, Yr.) January 13, 2017 June 4 1945 24b. TIME OF DEAN 17 00633 Hospice Facility 9g. INSIDE CITY LIMITS 5a YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) January 18, 2017 STATE Nebraska 17b. Zip Code 68801 APPROXIMATE INTERVAL onset to death 2 Months onset to death onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES .0 No 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® 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) 24d. TIME PRONOUNCED DEAD 240. On the ba,iu Ci ..Yain,.,ot10n u,.3, J, ,,neat tat! .t, i:3:n p....ar dca2h Zcvnrred S: the time, date and place and due to the cause(s) stated. (Signature and Tdle) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ .NO 28b. DATE FILED BY REGISTRAR ( January 19, 2017 0) r N CO