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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 />DATE OF ISSUANCE
<br />12/12/2016
<br />LINCOLN NEBRASKA
<br />STATE OF NEBRASKA
<br />201701344
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE. OF DEATH
<br />STANLEY S. VOOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />7. SOCIAL SECURITY NUMBER
<br />505-40 -0177.
<br />rib: FACILITY-NAME (It not institution give street and number)
<br />Kearney Regional Medical Center
<br />W
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Ernest Wayne Gifford
<br />4. CITY AND STATE OR TERRITORY OR FOREIGN COUNTRY OF BIRTH
<br />Friend, :Nebraska::
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Kearney 68845:
<br />9a. RESIDENCE-STATE
<br />LA.
<br />a
<br />at
<br />11. FATHER'S-NAME (First, Middle, Last, Suffix)
<br />Raymond Gifford
<br />0 .
<br />E
<br />$.
<br />2
<br />0
<br />Sa. AGE - Last Birthday
<br />(Yrs.)
<br />82
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />DOA
<br />9s. CITY OR TOWN
<br />Grand island
<br />9d. STREET AND NUMBER
<br />318 South Kimball
<br />1.t a. MARITAL STATUS'AT OF DEATH ® Married ❑ Never Married
<br />0 Married; but separated ❑ Widowed ❑ Divorced 0 Unknown
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes; No or Unk) Yes . ;10/06/1952- 12 /02/1952
<br />15. METHOD OFDIISPOSITION
<br />❑ Burial ` ❑ Donation
<br />E Cremation 0 Entombment
<br />Removal ::; 0 Other (Specify)
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />::sequentially) t conditions: if .
<br />any, ieading:to the cause'ltsted
<br />on line a.
<br />Entef the UNDERLYING CAUSE
<br />"(iliseaceor:Injury :that Irene*
<br />•::the events resulting:In death)
<br />LAST €
<br />20. IF FEMALE: `yr
<br />Not pregnant past year
<br />El Pregnant at time of death
<br />Not:pi.!egnant but pregnant within 42 days of death
<br />❑ Not pregnant: but pregnant 42 days to 1 year before death
<br />Unknown if pr egnat : the pest year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />82d.. I41JURy:ArWORK7
<br />❑. YES ONO ; :.
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a.. DATE OF:DEATH (Mo., Day, Yr.)
<br />December 4, 2016
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 5, 2016
<br />16a. EMBALMER-SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />TO, OR AS A CONSEQUENCE OF:
<br />b) Renal Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)Aspiration Pneumonia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />22b. TIME OF INJURY
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />23c. TIME OF DEATH
<br />02:54 PM
<br />Id. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Tito)
<br />:.Alfa MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ❑ NO ❑ PROBABLY gl UNKNOWN
<br />[28a REGISTRAR'S SIGNATURE
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide 0 Gould net be determined
<br />CITY/TOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Alla Liberstein, .. MD, 816 22nd Ave Suite 100, Kearney, Nebraska, 68845
<br />DAYS
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />OTHER ❑ Nursing Home/LTC
<br />Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Buffalo
<br />9e. APT. NO.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 4, 2016
<br />6. DATE OF BIRTH.(Mo.c:Day ye.).
<br />January 16, 1934
<br />9f. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Last, Suffix) If wife, give maiden name
<br />Doltie °Euceida:: Purse!!
<br />1 .12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Edith Mash
<br />14a. INFORMANT-NAME
<br />Dollie Euceida Gifford
<br />16b LICENSE NO.
<br />CITY I TOWN
<br />Gibbon
<br />17a. FUNERAL TOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />CAUSE QF DEATH (See instructions: and exam:110f)
<br />15 PART 1. Enter than chain of events - -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest; or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Cardiopulmonary Arrest
<br />18. PART II. OTHER SIGNIFICANT CONDIT ONS- Conditions contributing to the death but not resulting in the underlying cause given in P ART I.
<br />2111. *TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />Pedestrian
<br />QOther (Specify)
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 7 e
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />❑ Hospice Facility
<br />9g. INSIDE CITY LIMITS'
<br />® YES ❑ NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16c. DATE (Mo., WI% Tr.) :; .. .;:; :.
<br />December 7, 2016
<br />STATE
<br />Nebraska
<br />17b. Zip. Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Minutes
<br />onset to death
<br />Days !;
<br />onset to death
<br />Days
<br />onset tC heath ;
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ! El NO
<br />21e. WAS AN AUTOPSY : PERFORMED?
<br />.;;
<br />❑ YEs E NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABL
<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 />ZIP CODE
<br />24b. TIME OF DEATH ..:
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and /or Investigation, In my epblon death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26b. WAS CONSENT GRANTED/
<br />Not Applicable if 26a Is NO O YES 0 N
<br />28b. DATE FILED BY REGISTRAR (MO., Day, Yr.)
<br />December 6, 2016
<br />
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