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te 4� >wl A.wnPk �9 A,bt .., _.. SA.,x STATE OF NEBRASKA a'a °'x.B4AA earl 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 DATE OF ISSUANCE 3/8/2017 LINCOLN, NEBRASKA 201702730 awl STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Darrel Lee Brannagan 4. CiTYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Adams County, Nebraska I 7. SOCIAL SECURITY NUMBER 505 -42 -3133. 8h FACILITY -NAME (If not Institution, give street and number) tt d 1511 Post Place ce 8c. CITY OR TOWN OF DEATH (Include Zip Code) G Grand Island 68801 K 9s. RESIDENCE - STATE Nebraska E 9d. STREET AND NUMBER • 1511 Post Place a xt 10a. MARITAL STATUSAT TIME OF DEATH ® Married ❑ Never Married ❑ Married, butseparated:', ❑ Widowed ❑ Divorced ❑ Unknown 1. FATHER'S NAME (First, Middle, Last, Suffix) Arvene Brannagan at w I 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 8 (Yes, No, or Unk.) Yes 10/21/1958-10/20/1960 It 15. METHOD OF DISPOSITION ,2 El Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) IMMEDIATE CAUSE (Final disease or condition resulting m. death) aegyentiaily (inn coniitions. ir b) •any, leadmp to the cause listed on Enter the UNDERLYING CAUSE t dise as e or m)ury:ihat initiated the eveids reslrlting death) LAST 0. IF FEMALE; ❑ Not pregnant within past year ❑ Pregnant at time of death • ❑ Not pregnant,but pregnant within 42 days of death ❑ Not pregnae! but pregnant:i3 days to 1 year before death ❑ RilknOwn d pregnant with fl the past year E 22a. DATE OF INJURY (Mo., Day, Yr.) O t.) C 22d.:INJURYAT!WORK9 ::❑ YES • Q NO 16a. EMBALMER-SIGNATURE a) Liver Cancer Katie M. Smvdra DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: C) DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO. CITY/TOWN 25. DID TOMACCO USE CONTRIBUTE TO THE DEATH? a YES 12 Na `❑ PROBABLY ❑ UNKNOWN 5a. AGE - Last Birthday (Yrs.) 81 9b. COUNTY Hall 16d. CEMETERY, CREMATORY OR OTHER LOCATION Grand Island City Cemetery 7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska 23a. DATE OF DEATH (Mo., Day, Yr.) February 23, 2017 23b DATE SIGNED (Mo., Day, Yr.) February 24, 2017 23c. TIME OF DEATH 12:40 PM v uu O 3d. To the best of my knowledge, death occurred at the time, date and place c and due to the cause(s) stated. (Signature and Title) o John A. Wagoner, MD 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print John A. Wagoner, MD, 800 N Alpha Street, Grand Island, Nebras - c 28a. REGISTRAR'S SIGNATURE - Corot"- 5b. UNDER 1 YEAR MOS. DAYS 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide Q Could not be determined 9c. CITY OR TOWN Grand Island 9e. APT. NO. 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES NO 2. SEX Male 5c. UNDER 1 DAY HOURS CITY /TOWN Grand Island STATE MINS. 8d. COUNTY OF DEATH Hall CAUSE OF DEATH (See instructions and examples) to PART I. Enter the chain of events -- diseases, injuries, or complications -that directly caused the death. DO NOT entertenninal events such as cardiac arrest, fsapiratoty arre8t, or ventritular fibrillation without showing the etiology. DO NOT ABBREVIATE. Etter only one cause on a line. Add additional lines it necessary. IMMEDIATE CAUSE: 21b. IF TRANSPORTATION INJURY Driver /Operator ❑ Passenger ❑ pedestrian 0 Other (Specify) 3. 6 9f. ZIP CODE 68801 Suffix) If wife, gi 10b. NAME OF SPOUSE (First, Middle, Last, LaVila K Hammer i 12. MOTHER'S -NAME (First, Middle, Maiden Theresa Phillips 14a. INFORMANT -NAME LaVila Brannagan 16b. LICENSE NO. 1454 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in P Chronic Obstructive Lung Disease ART I. 22c. PLACE OF INJURY -At home, farm, street, factory, office building, cons 24a. DATE. SIGNED (Mo., Day, Yr.) 24b. 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. 24e. On the basis of examination and/or investiga ion, i n the time, date and place and due to the cancels) s 26b. WAS CON Not Applicable if DATE OF DEATH (Mo., Day, Yr) February 23, 2017 . DATE OF BIRTH (Mo,, ;Day,Yr, January 30, 1936 OTHER El Nursing Home /LTC El Hospice Facility ® Decedent's Home El Other (Specify) ve maiden name Surname) onset to deat onset to death ES [D NO ruction site, etc. (Specify) TIME OF DEATH SENT GRAN '7 26a is NO ❑ Y 28b. DATE FILED BY REGISTRAR (MO., Day, Yr.) March 2, 2017 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE IMo., Day, Yr.) February 28, 2017 STATE Nebraska 17b. Zip Code 68601 APPROXIMATE INTERVAL onset to death lyear 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑YES 40.0 21c. WAS AN AUTOPSY PERFORMED? ❑YES 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? TIME PRONOUNCED DEAD my opinion death occurred at ted. (Signature and Tile) W 00