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410' ° Y4.» ` i 444.1 .ww ef' X AX i ■ d e STATE OF NEBRASKA a t 1gl �a,pFfl` 4.'• WHEN THIS 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 � VITTAL RECORDS DATE OF ISSUANCE 201705089 7/18/2017 LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. ''COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Monte Charles Perkins 4, CITYANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 505 -82 -701.9 8b. FACILITY -NAME (If not`Institution, give street and number) 341 1 East Seedling Mile Road 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 9a. RESIDENCE -STATE Nebraska 108. MARITAL STATUS AT Tun OF DEATH ® Married ❑ Never Married 0 Married, but separated ! ❑ Widowed ❑ Divorced ❑ Unknown 9b. COUNTY Hall sc.c1tYORTOWN I Grand Island 9d. STREET AND NUMBER 3411 East Seedling Mile Road 11. FATHER'S -NAME (First, Middle, Last, Suffix) Francis Perkins Jr 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Jeanette Lacy 13; EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or U1ik.) (NO 16. METHOD OF DISPOSITrON ® Burial ❑ Donation ❑ Cremation ❑ Entombment Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Chris McCoy 16d. CEMETERY, CREMATORY OR OTHER LOCATION Grand Island City Cemetery CITY /TOWN Grand Island STATE Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd. Grand Island. Nebraska CAUSE OF DEATH (See instructions and examples) it APART I. Enter the chain of events- - diseases, injuries, or complications -that directly caused the death, DO NOT ants; terminal respiratory emit, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter' only one cause on a IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Acute Myocardial Infarction disease or condition resulting In death) events such as cardiac arrest, line. Add additional lines if necessary. APPROXIMATE IN TERVAL onset to death Minutes DUE TO, OR AS A CONSEQUENCE OF: Sequelltiallyasf conditions, if b) Coronary Arteriosclerosis any, leading to the cause listed onset to death Months onset to death Months • DUE TO, OR AS A CONSEQUENCE OF: Enter Me UNDERLYING CAUSE c) Chronic Obstructive Pulmonary Disease Idlseasa er injury t of initiated the events resulting in death) LAST 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 I. 20. II FEMALE: ❑ Not pregnant within past year 0 Pregnant at time of death ❑ Not pregnant;, but pregnant within 42 days of death •❑ Not pregnantu pregnant 43 days to 1 year before death • ❑ Unknown if (,regnant Withinthe past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY ATWORK? . • ❑YES ❑CIO 8 F 23b, DATE SINNED (Mo., Day, Yr.) 5 z • a O o W 22b. TIME OF INJURY 5a. AGE - Last Birthday (Yrs.) 58 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined t 6b.? UNDER 'I YEAR M OS. DAYS 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) July 11, 2017 6. DATE OF BIRTH (Mo., Day = Yr.) September 14, 1958 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ® Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Hall 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian Other {Specify) 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ❑ YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Sheryl Ann Bly 14a. INFORMANT -NAME Sheryl Ann Perkins 16b+ LICENSE NO. 1191 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) July 14, 2017 17b. Zip<Code 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NQ 21c. WAS AN AUTOPSYI>ERFORMED7 ❑ YES ❑ 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) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. C ITY /TOW STATE 23a, DATE OF DEA.. TH (Mo., Day, Yr.) 23c. TIME OF DEATH 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 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) Ashley A. Dorwart, Deputy Hall County Attorney 24a. DATE;, SIGNED (Mo., Day, Yr.) July 13, 2017 24c. PRONOUNCED DEAD (Mo., Day, Yr.) July 11,2017 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES Ei NO 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YEs ❑ NO ❑ PROBABLY E UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ashley A. Dorwart, Deputy Hall County Attorney, 231 South Locust Street, Grand Island, Nebraska, 68802 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR July 13, 2017 24b. TIME OF DEATH Approx. 02:00 AM 24d. TIME PRONOUNCED D 07:15 AM 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO