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STATE OF NEBRASKA I "tad I...I U ryh tl °y a Sir WHEN THIS ~ COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE IA 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 2/23/2017 OLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Gary Eugene Dadey 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Phillips, Nebraska 7. SOCIAL SECURITY NUMBER 506 -46 -1643 FACILITY -NAME (If not Institution, give street and number) 2519W Oklahoma Ave a. RESIDENCE -STAT Nebraska 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island: 68803 9d. STREET AND NUMBER 2519 W. Oklahoma Ave 15. METHOD OF Dt$PQSITION ❑ Burial 0 Donation ® Cremation ❑ Entombment Removal ❑ Other (Specify) 8a. REGISTRAR'S SIGNATURE 9b. COUNTY Hall 1Ua. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Harold Dadev 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes No, Or unk,) Yes ,10/15/1957- 10/15/1960 16a. EMBALMER - SIGNATURE Not Embalmed CAUSE OF DEATH 5a, AGE - Last (Yrs.) 77 14a. INFORMANT -NAME Marla Faye Dadev 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services Fla. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska c 201.704645 t$. 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 on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) unknown Natural Causes disease or condition resulting in death} Sequentially Ilst conditions, If any, leading to the cause listed on line a. .. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) ) -Basses or injury ttiat Initietea h . ...._ .. the avems rasglnng:in death) :. LAST DUE TO, OR AS A CONSEQUENCE OF: b) Diabetes 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 1. APPROXIMATE INT3 onset to death Hours onset to dea Years onset to death VAt : 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES Q NO 20. IF:EEMALE: • ❑ Not pregnantwlthin past year Q Pregnant at time of death. 0 Notpregnam, but pregnant within 42 days of death Q Nat pregnant, but pregnant 43 days to 1 year before death ❑ •Urtknewn if pregnamwitie the past year 22a. DATE OF INJURY (Mo., Day, Yr.) INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED ©YES ❑NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 23a DATE OF DEATH (Mo., Day, Yr.) 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined I 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) CITY/TOWN 214. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED/ ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other(Specify) ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? ❑ YES 0 N STATE "ZIP CODE 24b. TIME OF DEATH Approx. 09:40 PM 23b. DATE S($NED (Mo., Day, Yr.) • 23c. TIME OF DEATH 24a. DATE SIGNED (Mo., Day, Yr.) x February 10, 2017 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD E ' " February 8, 2017 09:26 PM 3d. To the beat of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO 0 PROBABLY ® UNKNOWN 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) Nancy Berger- Schneider, Hall Deputy County Attorney: 26a. HAS ORGAie pa TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? ❑ YES lE NO Not Applicable if 26a is NO ❑ YES 0 NO STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Irthday 5b. UNDER 1 YEAR MOS. DAYS 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient Q DOA 90. CITY OR TOWN Grand Island 10b. NAME OF SPOUSE (First, Marla Faye Bailey See instruc 12, MOTHER'S -NAME (First, Middle, Maiden Surname) Johanna Larson 9e. APT. NO. STANLEY S.1rOOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 2. SEX Male 8d. COUNTY OF DEATH Hall Middle, Last, Suffix) If wife, give maiden name 16b« LICENSE NO. d exam . les 5c. UNDER 1 DAY CITY / TOWN Gibbon HOURS ate MINS. OTHER ❑ Nursing Home /LTC ® Decedent's Home ❑ Other (Specify) 9f. ZIP CODE 68803 3. DATE OF DEATH (Mo., Day, Yr.) February 8, 2017 6. DATE OF BIRTH (Mo., Day, Yr.) October 16, 1939 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT. Spouse 16c. DATE (Mo., Day, Yr.) February 13, 2017 `17 01$89 Hospice Facility STATE ebraska 17b. Zip Co 68801 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Nancy Berger - Schneider, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 28b. DATE FILED BY REGISTRAR (Ma Day, Yr.), February 13, 2017