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.15 STATE OF NEBRASKA WHEN nos !'' COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES TIE 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 1/11/2017 LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) James Cemper 4: CI AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH David. City Nebraska 7. SOCIAL SECURITY NUMBER 507 -52 -6533 FACILITY -NAME (If not Institution, give street and number) 40 West 13th Street 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 a RESIDENCE- STATE Nebraska 9d. STREET AND NUMBER 403 West 13th Street 10a. MARITAL STATUS AT. TIME OF DEATH Married (J Never Married Married but separated. 0 Widowed ❑ Divorced ❑ Unknown 1. FATHER'S-NAME (First, Middle, Last, Suffix) Anton Cemper 13. EVER IN U.S. ARMED . Give dates of service if Yes. (Yes Na, or Unk.) No 5. ME THOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Derek Apfel 14a. INFORMANT -NAME Sharon Cemper 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services 7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)':' Apfel Funeral Home. 1123 W. 2nd. Grand Island, Nebraska 14.FAfTt. Enter th iratory ,ar IMMEDIATE CAUSE (Final disease or condition resulting in death) .. . Sequentially hat CO4d bete, if •any, tending to the ca use listed on line a. .. Enter the UNDERLYING CAUSE (disease or tnjury:tliat indtaled. the events reCUktng 1,1 death) 1.AST�: 0. IF :FEMALE: ❑ Not pregnam within past year ❑. Pregnant at time of death.. 0 N pregeatd,but pregnant within 42 days of death ❑ Not pre0ttam, put pregnam 43 days to 1 year before death ❑ Unkntlw11 if prdgnant tiithiir the past year 22a. DATE OF INJURY (Mo., Day, Yr.) JURY AT WORK YES ❑ NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 23a DATE OF DEATH (Mo., Day, Yr.) December 28, 2016 DATE alxrNEF, (11(o., pay, Y,.) I 23c. EI",TI1 December 30, 2016 I 03:45 PM 3d. To the best of my knowledge, death occurred at the time, date and place and due 'tothe cause(s) stated. (Signature and Title) Monica L McDonald, APRN 8a.REGISTRARS SIGNAT'.0 RE DUE TO, OR AS A CONSEQUENCE OF: b) 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 20 1703295 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 5a. AGE - Last Birthday {Yrs.) 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could 1101 be determined CITY/TOWN 7 , 5b. UNDER 1 YEAR MQS, 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN. Grand Island' 9e. APT. NO. Ob. NAME OF SPOUSE (First, ; Middle, Last, Suffix) If wife, give maiden name. Sharon Meyer 1 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Marie Schmid CAUSE OF DEATH (See instructions and examples) 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Monica L. McDonald, APRN, 2116 W. Faidley Avenue, Grand Island, Nebraska, 68803 DAYS 16b. LICENSE NO. 1240 2. SEX Male Gibbon 5c. UNDER 1 DAY HOURS CITY / TOWN STATE 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? i1 YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES 1 NO A6 ate STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES MINS. OTHER ❑ Nursing Home /LTC ® Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68801 haul 01 events- -diseases, injuries, or complications -that directly caused the death. 00 NOT enter terminal events such as cardiac arrest, or ventr(eular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line, Add additional lines A necessary. IMMEDIATE CAUSE: a) Small Cell Lung Cancer, Metastatic 18. PART 1L OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Chronic Obstructive Pulmonary Disease 21b: IF TRANSPORTATION INJURY 0 Driver /Operator 0 Passenger ❑ Pedestrian Ei Other(Specify) z :a 24a. DATE SIGNED (Mo., Day, Yr.) v rn E o 24f'. PPONC(IhI .En r)FAD - (Mo.. Day. Yr .t > °u C O o z § January 5, 2017 August 7, 1945 3. DATE OF DEATH (Mo., Day, Yr.) December 28, 2016 6. DATE OF BIRTH (MO,, Da Y ❑ Hospice Facility 9g. INSIDE CITY IJMITS YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr. January 3, 2017 STATE Nebraska' 17b. Zip Code 68801 APPROXIMATE INTERVAL onset to death 20 Months 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED? E: ❑ YES Q NO 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) ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Tide) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ N 28b. DATE FILED BY REGISTRAR (Mo Day, Yr.)