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.,.i, ;•N l, \d \ A natimvk v 7/a „ t ,irk STATE OF NEBRASKA t*. wer-Zi;r5vistnkise WHEN THIS I'' 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 1/4/2017 LINCOLN, NEBRASKA 201 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES I 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Lois June Porter PART I. 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 pn a line. Add additional lines if necessary. IMMEDIATE CAUSE (Final disease or condition resulting IMMEDIATE CAUSE: a) Respiratory Failure /sepsis 3 Days APPROXIMATE INTERVAL. 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Amsterdam: Missouri 7. SOCIAL SECURITY NUMBER 508 -40- 2269 K 8b. FACILITY -NAME (If not Institution, give street and number) 0 1 G CHI Health St. Francis ce 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand. Island 68803 g 9a. RESIDENCE•STATE L I Nebraska • 9d. STREET AND NUMBER U. • 1603 Park Avenue 18a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑II/larrled, but separated; E Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Jesse Gregory lob. NAME OF SPOUSE (First, Middle, Last, Cecil R Porter 1 12. MOTHER'S -NAME (First, Ruby Summers Suffix) If wife, give maiden name Middle, Maiden Surname) E 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 8 (Ye$, No, or Unit.) No 2 15. METHOD OF DISPOSITION F E Burial 0 Donation ❑ Cremation ❑ Entombment 0 Removal ❑ Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)'i Acfel Funeral Home, 1123 W. 2nd. Grand Island, Nebraska Enter the UNDERLYING CAUSE :(disease or atjurn that initiated.::. the eve result nts ing m deathl ;. t.AST.< .. 0. IF FEMALE:. ❑ Not Pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, knit pregnant of death ❑ Not praynadt, but pregnant 4.3 days within 42 to days 1 year before death ❑ 4lthk1b . it prsgnantwitten the past year 0 . N fr 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY 224. . INJURY AT :WORK ❑YES . ONO 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 25. DID TOBACCO USECONTRIBUTE TO THE DEATH? ❑ YES ENO ❑ PROBABLY ❑ UNKNOWN 5a. AGE' ' Last Birthday (Yrs.) 91 9b. COUNTY Hall 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Cemetery 22e. DESCRIBE HOW INJURY OCCURRED 23a. DATE OF DEATH (Mo., Day, Yr.) December 22, 2016 a 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ° December 27, 2016 02:30 PM O Z o a 0 3d. To the best of my knowledge, death occurred at the time, date and place 2 c and due to the cause(s) stated. (Signature and Title) o Ryan D. Crouch, DO bb. UNDER 1 YEAR M OS. DAYS HOURS 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 9c. CITY OR TOWN Grand island` 9e. APT. NO. 14a. INFORMANT -NAME Wayne Porter 16a. EMBALMER-SIGNATURE Christopher J. Loecker 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be detelmined CITY /TOWN 16b LICENSE NO. 1421 CITY I TOWN Grand Island CAUSE OF DEATH See instructions and examolesl P death) Secpue tiallyiist Senditions, if any, reeding 10 the: cause listed on line a DUE TO, OR AS A CONSEQUENCE OF: b) Pneumonia onsettoi4eo th 3 Days DUE TO, OR AS A CONSEQUENCE OF: C) onset to death DUE TO, OR AS A CONSEQUENCE OF: d) onset fO death I 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Polyrnyalgia Rheumatica, Hypertension 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other /Specify) 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS OR ❑ YES N OR TISSUE DONATION BEEN CONSIDERED? E NO 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 Title) 27, NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803 REGISTRAR'S SIGNATURE 2. SEX Female 5c. UNDER 1 DAY MINS. 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68803 3. DATE OF DEATH (Mo., Day, Yr.) December 22, 2016 6. DATE OF BIRTH (MO., Day, Yt.):. June 19, 1925 9g. INSIDE CITY LIMITS'' DD YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Son 16c. DATE (Mo., Day, Yr.) December 27, 2016 STATE Nebraska 17b, Zip Code 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES EI NO 21c. WAS AN AUTOPSY PERFORMED? ❑YES ENO 21d. WERE AUTOPSY. FINDINGS AVAILABLE TO COMPLETE CAUSE Of DEATH?:: ❑YES 0 N 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 26b. WAS CONSENT GRANTED7 Not Applicable if 26a is NO ❑ YES 28b. DATE FILED BY REGISTRAR (MO,, Day, Yr.) December 28, 2016