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<br />STATE OF NEBRASKA
<br />tY
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />7/18/2017
<br />LINCOLN, NESRASKA
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Gilbert Lewis Johnson
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507 -36 -3249
<br />8b FACILITY -NAME (If not Institution, give street and number)
<br />Veterans Affairs Medical Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a, RESIDENCE-STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />822 W 14th St
<br />1. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Andrew Johnson
<br />13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes,: No, or Unk.) Yes 11/01/1956-10/31/1958
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑ Donation
<br />Cremation ❑ Entombment
<br />Removal fl Other {Specify)
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially not condntona, d b)
<br />any, leading to Ova cause listed
<br />on line a. - - -..
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease Or injury that initiated
<br />the events resualtrgltt death}
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST >, d)
<br />20.IFFEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />❑ Nol pregdent, but pregnant 41 days to 1 year before death
<br />❑ Unknown If pregnant whin the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />220: IN.(URY AT WORK?
<br />❑ YES Q:NO
<br />22f. LOCATION OF INJURY STREET& NUMBER, APT.NO.
<br />238, DATE OF DEATH (Mo., Day, Yr.)
<br />J U Iy 3, 2017;
<br />23b, DATE SLG 4EE) (Mo., Day, Yr.) 123c. TIME OF DEATH
<br />July 5, 2017 1 07:45 AM
<br />3d. To the best of my knowledge, death occTirred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Shawn S. Lawrence, MD
<br />28a. REGISTRAR'S SIGNATURE
<br />201 '705 0
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />16a. EMBALMER-SIGNATURE
<br />Not
<br />9b. COUNTY
<br />Hall
<br />Embalmed
<br />Westlawn Memorial Park Crematory
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />83
<br />14a. INFORMANT-NAME
<br />Judy Johnson
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />5b. UNDER 1 YEAR
<br />OS.
<br />9C. CITY OR TOWN
<br />Grand island
<br />a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Livingston- Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska
<br />22b. TIME OF INJURY
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />CITY /TOWN
<br />El NO
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />Q DOA
<br />9e. APT. NO.
<br />16b. LICENSE NO.
<br />2. SEX
<br />Male
<br />HOURS
<br />CITY / TOWN
<br />Grand Island
<br />25, DID 'MBA DOUSE CONTRIBUTE TO THE DEATH? 26a, HAS ORGAN TISSUE DONATION BEEN CONSIDERED?
<br />J YES 0 N ❑ PROBABLY ❑ UNKNOWN ❑ YES
<br />27. N, TITLE ADDRESS TI ( Te or Print
<br />Shawn S. Law , MD , 223 CER South FIER E yp St, Broken Bow, Nebraska, 68822
<br />STANLEY S. *COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />5c. UNDER 1 DAY
<br />MINS.
<br />OTHER ❑ Nursing Home /LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />18d. COUNTY OF DEATH
<br />Hall
<br />9f. ZIP CODE
<br />68803
<br />CAUSE OF DEATT-I (See instructions and examples)
<br />18. PART I. Enter the chain otevents- -diseases, injuries, or complications -that directly caused the death. DO NOT entertanninal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter Only one cause on a line. Add additional lines d necessary.
<br />IMMEDIATE CAUSE:
<br />a) Metastatic Prostate Carcinoma
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />CHF, COPE), Debility
<br />21b: IF TRANSPORTATION INJURY
<br />❑ (river /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />Other (Specify)
<br />Coe
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Frances Govier
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />July 3, 2017
<br />too, MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Judy Berney
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />24e. On the basis of examination and /or investiga ion, in my Opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Tdde) :
<br />9g. INSIDE CITY LIMITS
<br />YES ❑ No
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />July 6, 2017
<br />STATE
<br />Nebraska
<br />17b. ZIP: de
<br />68803
<br />APPROXIMATE INTERVAL';
<br />onset to death''
<br />2 Years
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES aa NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)j 24d. TIME PRONOUNCED DEAD
<br />28b. DATE FILED BY REGISTRAR Mo., Flay, Yr.
<br />July 10, 2017
<br />NO
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