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STATE OF NEBRASKA nzirr z. LL a 4, 4 , 4, 4, a. E 0 1. DECEDENTS - NAME (First, Middle, Last, Suffix) Larry Gayle Wells 4. CITY ND STAT OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Elba, Nebraska 7. SOCIAL SECURITY NUMBER 505 -56 -7137 FACILITY•NAM 307 W,18th1 8c. CITY OR TOWN OF DEATH (Include Z ip Code) Grand Island 68801 ea.: RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 307 W. 18th 10a. MARITAL STATUS AT TIME OF DEATH I)SI Married U Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Harland Wells 13 EVER IN U.S, ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk,) NO 15. METHOD OF DISPOSITION b ❑ Burial ❑ Donation ® Cremation ❑ Entombment 0 Removal ;❑ Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Jacobsen- Greenwav Funeral Home, 411 0 Street. PO Box 112, St. Paul. Nebraska 1E, FART'. Enter the ;:chain of events-diseases, injuries, or complications -that directly caused the death, 00 NOT enter terminal events such as cardiac arrest, respiratory arrestor 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 disease or condition resulting 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 5/12/2017 LINCOLN, NEBRASKA Sequentially list candltion: any, leeding cause ii Enter the UNDERLYING CAUSE (disease drinjury that mrtiated.. the 545015 re501hlg ":In death) LAST E (If not Institution, give street and number) DUE TO, OR AS A CONSEQUENCE OF: b) Asthma DUE TO, OR AS A CONSEQUENCE OF: c) Heart Disease DUE TO, OR AS A CONSEQUENCE OF: d) 0. IF FEMALE: ❑ Not pregnant wehin past year ❑ Pregnant at time of death 0 Not pregnant, but pregnant within 42 days of death ❑ NM pregnant, but pregnant 43 days tot year before death ❑ Unknown if pregnantwlthin the past year 22a. DATE OF INJURY (Mo., Day, Yr.) d. INJURY AT WORK? :. YEs ❑ NO 22f. LOCATION OF INJURY- STREET& NUMBER, APT.NO. 3a, DATE OF DEATH (Mo., Day, Yr.) 212. DATE SIGNED (Mo., Day, Yr.) 5. To the best of my knowledge, death occurred at the time, date and were alai. due to the causets) stated. ( Signatdre and Title) 201703136 STATE OF NEBRASKA - DEPARTMENT <OF HEALTH! AND HUMAN SERVICES CERTIFICATE OF DEATH 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE William D. Greenwav 220. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 23c. TIME OF DEATH 5a, AGE - Last Birthday (Yrs.) 74 14a. INFORMANT-NAME Karen Wells 16d. CEMETERY, CREMATORY OR OTHER LOCATION 28a. REGISTRAR'S SIGAtAT(YRE /lar�� aetlfir 50; UNDER 1 YEAR MOS. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑pEIER/Outpatient DOA 9c. CITY: OR TOWN Grand Island 100. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Karen Sack 1 12. MOTHER'S -NAME (First, Middle, Rosabelle Larsen Central Nebraska Cremation Services Gibbon CAUSE OF DEATH (See instructions and examples) 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation 0 Suicide ❑ Could not be determined DAYS 160, LICENSE NO. 0913 2. SEX Male 5c. UNDER 1 DAY HOURS 8d. COUNT' OF DEATH Hall 9e. APT. NO. 9f. ZIP CODE 68801 CITY / TOWN 210. IF TRANSPORTATION ❑: Driver /Operator ❑ Passenger ❑ Pedestrian Other(Specify) INJURY Coe STANLEY S. DDOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES MINS. OTHER ❑ Nursing Home /LTC El Decedent's Home ❑ Other (Specify) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 3. DATE OF DEATH (Mo., Day, Yr.) May 5, 2017 6. DATE OF BIRTH (M February 15, 1943 Maiden Surname) Wife pay, Yi ❑ Hospice Facility 99. INSIDE CITY LIMITS' ® YES ❑ NO 16c. DATE (Mo., Oay, Yr.) May 8, 2017 STATE Nebraska 1712, Zip Code 68873 APPROXIMATEINTERVA onset to dean} Minutes onset to death:::::: Years onset to death Months onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? El YES ❑ NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE . TO COMPLETE CAUSE OF DEATH7: ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) CITY /TOWN 5. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Joseph E. Dobesh, Deputy County Attorney, 231 S Locust St, Grand Island, Nebraska, 68802 Y .t z May 8, 2017 e �- May 5, 2017 (?6:33 PM , ,,,__ , ,� 2. 2 te. On the basis or examination cndior inves.iga ion., in my opinion death occurred at o . Q p the time, date and place and due to the cause(s) stated. (Signature and Tide) o E Joseph E. Dobesh, Deputy County Attorney 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? ❑ YES ED NO Not Applicable if 26a is NO ❑ YES ❑ NO 24a. DATE SIGNED (Mo., Day, Yr.) 240. PRONOUNCED DEAD (Mo., Day, Yr. STATE ZIP CODE 24b. TIME OF DEATH Approx. 03'00 PM 24d. TIME PRONOUNCED DEAD DATE FILED BY REGISTRARiMo, Oay, Yr. May 9, 2017