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kl g em f . / AWL `N /7 .: Made \ STATE OF NEBRASKA WHEN. THIS 'r 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 Clite RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 3/17/2017 LINCOLN, NEBRASKA 201703914 STAN S. OOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH E a. PART I. Enter the chain of events- -diseases, injuries, or complications-that directly caused the death DO NOT enterter minel 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) Multi -organ Failure disease or condition resulting in death) APPROXIMATEINTERVAL onset to death Days 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Thomas Edgar Moran 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Wellsboro, Pennsylvania 7. SOCIAL SECURITY NUMBER 164 -36- 0252 8b. FACILITY -NAME (If not Institution, give street and number) 0 8 CH1 Health St. Elizabeth ft 8c. CITY OR TOWN OF DEATH (include Zip Code) E Lincoln 68510 9a, RESIDENCE -STATE CC z Nebraska LL 9d. STREET AND NUMBER 2308 N. Custer Street an 10a. MARITAL STATUSAT TIME OF DEATH ® Married ❑ Never Married Married, but separated ' 0 Widowed 0 Divorced 0 Unknown 11. FATHER'S -NAME (First; Middle, Last, Suffix) Harry Moran a 13. EVER IN U.S ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 09/08/1961-09/04/1964 15. METHOD OF DISPOSITION Fd ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal 0 Other 17a, FUNERAL HOME NAME' AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island, Nebraska 20.IF::FEMALE: I - ' ❑ Not pregnant Within past year U ❑ Pregnant at time of death ❑ Not pregnant, bin pregnant within 42 days of death ❑ Not pregnant but pregnant 43 days to 1 year before death 2 2 ❑ Uitknavm it pregnant within the past year E 22a. DATE OF INJURY (Mo., Day, Yr.) 0 22d. INJURY ATWORK? ::! yes' O NO 23a. DATE OF DEATH (Mo., Day, Yr.) March 8, 2017 23b. DATE SIGNED (Mo., Day, Yr.) March 10, 2017 8a. REGISTRAR'S 3d. To the best of my knowledge, death occurred at the time, date and place and due to the causes) stated. (Signature and Title) Sean. Hansen. MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES Ea NO ❑ PROBABLY ❑ UNKNOWN :NATURE 16a. EMBALMER-SIGNATURE Not Embalmed 22b. TIME OF INJURY 23c. TIME OF DEATH 07:18 AM 5a. AGE Last Birthday (Yrs.) 74 9b. COUNTY Hall 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could net be determined MOS. 5b UNDER 1 YEAR DAYS HOURS 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Lancaster 9c. CITY OR TOWN Grand Island 9e. APT. NO. l ; 12. MOTHER'S-NAME (First, Pauline Matteson 14a. INFORMANT - NAME Sharon Sue Moran 16b. LICENSE NO. CAUSE OF DEATH (See instructions and examples) 2. SEX Male 5c. UNDER 1 DAY MINS. 9f. ZIP CODE 68803 Middle, Maiden Surname) 18. PART U. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Acute Kidney; Injury, Shock Liver, Atrial Fib, Pleural Effusion 21b. IF TRANSPORTATION ❑ Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other(Specify) INJURY 24a. DATE. SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ® YES ❑ NO 3. DATE OF DEATH (Mo., Day, Yr.) March 8, 2017 March 1, 1943 6. DATE OF BIRTH (Mo., Day, Yf.) 9g. INSIDE CITY LIMITS ® YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Sharon Sue Rasmussen 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) March 13, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon STATE Nebraska. • 17b. Zip Code 68801 Sequentially list condition, 1? any, leading td the cause listed on line a DUE TO, OR AS A CONSEQUENCE OF: b) Bilateral Methicillin Resistant Staph Au us Pneumonia Onset to death t> Days Ester the UNDERLYING CAUSE (disease or injury teat initiated • DUE TO, OR AS A CONSEQUENCE OF: c) Cryptogenic Pneumonia onset to death Days the events resutti LAST In death) DUE TO, OR AS A CONSEQUENCE OF: d) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES Ea NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF D ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY /TOWN STATE 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 ® NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Sean .Hansen, MD,, 555 South 70th Street, Lincoln, Nebraska, 68510 28b. DATE FILED BY REGISTRAR (Mo,, Day, Yr.) March 13, 2017