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DATE OF ISSUANCE
<br />12/12/2016
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />WHEN .: THIS : COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />201701161
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />18.:PART t Enter the ttiain of events- - diseases, injuries; or complications- that directly causerl the' death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or :ventricuIar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause' on a Iine.Add additional lines N necessary.
<br />IMMEDIATE CAUSE:
<br />g,MEDw7E CAUSE (final a) Pulseless Electrical Activity
<br />disease or condition resulting
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Minutes
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Alan Leroy Gruwell
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Alma, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507 -74 -7301
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Ix
<br />t-; CHI Health St. Francis
<br />ce
<br />• Grand Island 68803
<br />9a RESIDENCE - STATE
<br />Nebraska
<br />• 9d. STREET AND: NUMBER
<br />> 2016 Rainbow Road
<br />1Oa. MARITAL STATUS AT TIME OF DEATH I Married ❑ Never Married
<br />E ❑ "Married, but Separated: ❑ Widowed ❑ Divorced ❑ Unknown • 11. FATHER'S - NAME first, Middle, Last, Suffix)
<br />d,
<br />a
<br />E
<br />0
<br />.4)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />13. EVER U.S. FORCES? Give dates of service if Yes.
<br />(Ygs No.or Unk.) No
<br />16. METHOD OF::DESPOSITtON
<br />Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Retm4.val ❑ Other. (.Specify).
<br />Sa. AGE - Last Birthday
<br />(Yrs.)
<br />62
<br />9b. COUNTY
<br />Hall
<br />Herbert Gruwell
<br />� 17a. FUNERAL HOME NAMEAND MAILING ADDRESS (Street, City or Town, State).
<br />Wet :Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />$b. UNDER 1 YEAR
<br />MOS,
<br />DAYS
<br />9e. APT. NO.
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />9f. ZIP CODE
<br />68801
<br />1 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Betty Gates
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November 25, 2016
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />March 9, 1954
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />0 ER/Outpatient
<br />DOA
<br />OTHER ❑ Nursing Home/LTC ❑ Hospice Facility
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />'9c. CITY OR TOWN
<br />Grand Island
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />106. NAME OF SPOUSE (First, .. Middle, Last, Suffix) If wife, give maiden name
<br />Rebecca Koch
<br />14a. INFORMANT-NAME
<br />Rebecca:. Gruwell
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16a. EMBALMER- SIGNATURE
<br />Chris McCoy
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery .
<br />16b. LICENSE NO.
<br />1191
<br />Grand Island
<br />16c. DATE (Mo., Day, Yr.)
<br />November 30, 2016
<br />STATE
<br />N.etjraskt3
<br />170; Eip'Code
<br />68801
<br />CAUSE OF DEATH (See instructions and example&)
<br />�Se9Wentiaily 11510CnlS(tions;:if
<br />•:any :leSdtng le :the i0use.tteted ..,.
<br />• on linen • . .
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Thoracic Aneurysm - Probable
<br />Enter the UNDERLYING CAUSE
<br />; (lsease or:i! jury.that initiated
<br />. .
<br />the evente resuhinf# in death( ":
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />onset to death
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />Hypertension, Acute. Confusion, Metabolic Acidosis With Increased Lactic Acid, Bronchiectasis, Alcohol Use Obstructive Sleep
<br />,Apnea
<br />• 20. IFFEMAt£E
<br />.. 0 Not pregnant.yrltt,inpaetYear
<br />iW.1 ❑ Pregnant at time of death
<br />.:: ::. ..❑ Not pregnant, Out pregnant within 42 days of death
<br />0. Not pregnant but pregnant 43 days to 1 year before death
<br />Unknow:n.if pr4gnantwithn the past year
<br />£ 22a. DATE OF INJURY (MO., Day, Yr.)
<br />O
<br />1.)
<br />1,1 22d. INJURY AT WORK?
<br />• C.
<br />r ❑ YES: ❑:NO::;. ':.
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />Noverrber! 2016
<br />•••
<br />C LL.. .
<br />2t f .::
<br />n w
<br />t7 Z
<br />u a
<br />° 3d. To the best of my knowledge, death occurred at the tine, date and place
<br />E o and due to the causes stated. (Signature and Title)
<br />o
<br />KimberlvA: Mickels, MD
<br />23b. DATE SIGNED(Mo., Day, Yr.)
<br />December 6, 2016
<br />22b. TIME OF INJURY
<br />23c. TIME OF DEATH
<br />04:10 AM
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES Q NO ❑ PROBABLY ® UNKNOWN
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />r aa. REGISTRAR'S SIGNA '6-"
<br />21b IF TRANSPORTATION INJURY
<br />Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />0
<br />othertSpecify)
<br />24a. DATE. SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES Eg] NO
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES . ®. NO
<br />21c. WAS AN AUTOPSY PERFORMED ?:.
<br />❑ YES 13/1 NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction sits, etc. (Specify)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(*) stated (Signature end Title)
<br />26b. WAS CONSENT GRANTED ?_
<br />Not Applicable if 26a Is NO ❑ YES ❑ NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />December 7, 2016
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