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IYdA� STATE OF NEBRASKA I6 - A Nye7. 'id, wrath 1. DECEDENTS -NAME (First, Middle, Last, Suffix) 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 ISSLIAIVCE 5/19/2016 LINCOLN, NEBRASKA Robert R Brown 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH HallCounty Nebraska 7. SOCIAL SECURITY NUMBER 507-48-6570 Sb. FACILITY - NAME (If not Institution, give street and number) CHI Health St. Francis 8c, CITY OR TOWN OF DEATH (Include Zip Code) Grand island 68803 a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 202 East Pine i 0a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Ralph R Brown 1 EVER IN 1)5. ARMED FORCES? Give dates of service if Yes. (Yes, No, or unk.) Yes I<1958 -1960 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Rernoval >❑ Other? (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livinaston- Sutler- Volland Funeral Home. 1225 N. Elm. Hastinas, Nebraska 8 . PART 1. 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 a) Cardiac Arrest, Ventricular Fibrillation disease or condition resulting in death) Sequentially list conditions; if any, reading to the cause bated on line a. Enter the UNDERLYING CAUSE (disease: ee iNury .that initiated.: the events resulting m death) LAST 2d. it4JURY AT YES 0 NO STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 9b. COUNTY Hall 14a. INFORMANT -NAME Gloria Brown 16a. EMBALMER-SIGNATURE Gwen K. Hyronemus 16d. CEMETERY, CREMATORY OR OTHER LOCATION Rosedale Cemetery DUE TO, OR AS A CONSEQUENCE OF: b)Tobacco Use, Diabetes Type 2, Hypertension, DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not resulting in the underlying cause given in PART I. Chronio Myelogenous Leukemia 20. IF FEMALE: ❑ Not pregnam within pasi year 0 Pregnant at t Of death ❑ Not ptegnant Ilut pregnant within 42 days of death 0 Not py¢gnatt but Protgnant 43 days to 1 year before death ❑ u if pregnant withut the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. . DATE OF DEATH (Mo., Day, Yr.) April 80, 2016 & . 23 b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 111l May 4, 2016 12:28 AM u a 0 3d. To the best of my knowledge, death occurred at the time, date and place and due to the causels) stated. (Signature and Title) '- * I Jane A. McDonald, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 20.70284E 5a. AGE - Last Birthday 5b. UNDER 1 YEAR (Yrs.) 78 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient E ER/Outpatient ❑ DOA CITY /TOWN 10b.: NAME OF SPOUSE (First, Gloria Lenz 12. MOTHER'S -NAME (First, Mabel Gerdes CAUSE OF DEATH (See instructions and examples) 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Gould not be determined 21d. WERE AUTOPSY. FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 26a. HAS ORGAN! OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? ❑ YES la NO Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803, 28a, REGISTRAR'S SIGNATURE MO S. 9c, CITY OR TOWN Doniphan DAYS 9e, APT. NO. 16b. LICENSE NO. 1448 CITY / TOWN 0 Passenger 0 Pedestrian 0 Other(Specify) HOURS Rosedale STATE 24a. DATE SIGNED (Mo., Day, Yr.) STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 2. SEX Male 5c. UNDER 1 DAY MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68832 Middle, Last, Suffix) If wife, give maiden name Middle, Maiden Surname) 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED ? :�: 0 Driver /Operator ❑ YES ® NO 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PR ONOUNCED D 24e. On the basis of examination and/or investiga ion, in my opinion death occurred at the time dete and niece end r1 to the eruae(s) stated. (Signature and Tits) 28b. DATE FILED BY REGISTRAR (MO., Da May 6, 2016 3. DATE OF DEATH (Mo., Day, Yr.) April 30, :2016 6. DATE OF BIRTH (Mo., Da November 7 1937 ❑ Hospice Facility 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP. TO DECEDENT Wife 16c. DATE (MO., D May 7, 2016 STATE • Nebraska 17b, Zip Code 68901 onset to death onset :tea Years APPROXIMATE INTERV onset to .death hours 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? E YES Li NO 24b. TIME OF DEATH ZIP CODE , Yr.)