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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 />4/25/2017 <br />LINCOLN, NEBRASKA <br />STATE OF NEBRASKA <br />20170550! <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES <br />CERTIFICATE OF DEATH <br />STANLEY S.ICOOPER <br />ASSISTANT STATE REGISTRAR <br />DEPARTMENT HEALTH AND <br />HUMAN SERVICES <br />INNIMMIONI <br />U <br />a <br />w <br />N <br />w <br />U <br />• <br />I <br />1. DECEDENTS -NAME (First, Middle, Last, Suffix) <br />John Richard Eilts <br />4 : CITYAND STATE OR:TERRII.TORY, OR FOREIGN COUNTRY OF BIRTH <br />Wiota Iowa <br />7. SOCIAL SECURITY NUMBER <br />485 -40- 6505:. <br />rib. FACILITY -NAME (If not Institution, give street and number) <br />CHI Health'St. Francis <br />8c. CITY OR TOWN OFDEATH (Include Zip Cod <br />c Grand :island 68803 <br />99 <br />RESIDENCE-;STATE/ <br />Nebraska <br />9d. STREET AND NUMBER <br />4177 Mason Avenue <br />10a: MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married <br />❑ Married; but separated ❑ WIdowed ❑ Divorced ❑ Unknown <br />Last, Suffix) <br />14.EVER IN U. ARMED Give dates of service if Yes. <br />(Yes No, .or Unk.) Yes :07/14/1957 <br />15. METHOD:OF DISPOSITION <br />❑ Burial ❑ Donation <br />® Cremation ❑ Entombment <br />Removal ?[] Other (Specify) <br />Sequentially Mit conditions, if ;;::: " <br />any, Watling to the cause listed <br />on line a. <br />DUE TO, OR AS A CONSEQUENCE OF: <br />Enter the UNDERLYING CAUSE C) <br />. : idiseaeb Or injury gull Initiated <br />the events r death) ' ::::.: DUE TO OR AS A CONSEQUENCE OF <br />LAST : >.' d) <br />20. IF:FEMALE: <br />❑ Not pregnantw'thin past year <br />❑ Pregnant at time of death <br />Notprognant, but pregnant within 42 days of death <br />❑ Nat pregnam, but pregnarn 43 days to 1 year before death <br />UnknoWn if pregnant within the past year <br />22a. DATE OF INJURY (Mo., Day, Yr.) <br />22d. INJURY AT WORK? <br />:0 YES Q3NO <br />rwra OF r)EATH (Mn., Day. Yr.) <br />A Df1) 16, 2017 <br />22b. TIME OF INJURY <br />B • 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH <br />° z April 17, 2017 05:00 AM <br />B U 0 3d. To the best of my knowledge, death occurred at the time, date and place <br />G and due to the causes) stated. (Signature and Title) <br />• Adam:.Brosz. MD <br />25. DID.TOMACCO: USE CONTRIBUTE TO THE DEATH? <br />❑ YES El NO ❑ PROBABLY ❑ UNKNOWN <br />5a. AGE - Last Birthday <br />(Yrs.) <br />82 <br />9b. COUNTY <br />Hall <br />21a. MANNER OF DEATH <br />Natural ❑ Homicide <br />❑ Accident ❑ Pending Investigation <br />❑ Suicide ❑ Could not be determined <br />16a. EMBALMER-SIGNATURE <br />Not Embalmed <br />REGISTRARS SIGNATURE - 128a. <br />56. UNDER 1 YEAR <br />MOS. <br />DAYS <br />HOURS <br />8a. PLACE OF DEATH <br />HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC <br />❑ ER/Outpatient ❑ Decedent's Home <br />DOA.. ❑ Other (Specify) <br />Q Faculty <br />8d. COUNTY OF DEATH <br />Hall <br />9c. CITY OR TOWN <br />Grand Island <br />9e. APT. NO. <br />2. SEX <br />Male <br />5c. UNDER 1 DAY <br />MINS. <br />s1 <br />Ob. NAME OF SPOUSE (First; Middle, Last, <br />Barbara Johannsen .:..: <br />Suffix) If wife, give maiden name <br />11. FATHER'S -NAME (First, Middle, <br />Herman Eilts <br />1 12. MO'THER'S -NAME (First, Middle, Maiden Surname) <br />Wilma Hansen <br />14a. INFORMANT -NAME <br />Barbara Eilts <br />16b. LICENSE NO. <br />16d. CEMETERY, CREMATORY OR OTHER LOCATION <br />Central Nebraska Cremation Services <br />CITY / TOWN STATE <br />Gibbon Nebraska <br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) <br />ADfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska <br />CAUSE OF DEATH (See instructions and examples) <br />1& PAR?'I. Enter the 0ain :of -diseases, injuries, or complications -that directly caused the death. DO NOT tenninpt events such as cardiac arrest, <br />resplratory arreet or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only o n e cause on a line. Add additional lines if necessary. <br />IMMEDIATE CAUSE: <br />IMMEDIATE CAUSE (Final a) Acute T. Cell Leukemia Lymphoma <br />disease or condition resulting <br />al death) ::..::, DUE TO, OR AS A CONSEQUENCE OF: <br />210.0 TRANSPORTATION INJURY <br />❑ Driver /Operator <br />❑ Passenger <br />❑ Pedestrian <br />• ❑ othar(Spoiry) <br />26a. HAS ORGAN OR TISSUE DONATION; BEEN CONSIDERED? <br />❑ YES IR NO <br />9f. ZIP CODE <br />68803 <br />3. DATE OF DEATH (Mo., Day, Yr.) <br />April 16, 2017 <br />6. DATE OF BIRTH (Mo., Day, Yr4 <br />November 23;' 1934 <br />9g. INSIDE CITY' LIMITS <br />® YES ❑ NO <br />14b. RELATIONSHIP TO DECEDENT <br />Spouse <br />16c. DATE (Mo., DBy;'Yr.) <br />April 18, 2017 <br />17b. ZIP Code <br />68801 <br />APPROXIMATE INTERVAL <br />onset to death <br />5 Months <br />onset to death <br />onset to death <br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. <br />Diabetes Mellitus Type 2, Chronic Obstructive Pulmonary Disease, Pulmonary Embolus,: Left Deep Venous Thrombosis, <br />Hypertension <br />19. WAS MEDICAL EXAMINER <br />OR CORONER CONTACTED? <br />❑ YES 5i1 NO <br />21c. WAS AN AUTOPSY PERFORMED? <br />❑ YES 15a NO <br />21d. WERE AUTOPSY FINDINGS AVAILABLE <br />TO COMPLETE CAUSE OF DEATH? : <br />❑ YES ❑ NO <br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) <br />22e. DESCRIBE HOW INJURY OCCURRED <br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. <br />CITY/TOWN <br />STATE <br />ZIP CODE <br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH <br />24c. PRONOUNCED DEAD (Mo., Day, Yr.l 24d. TIME PRONOUNCED DEAD <br />24e. On the basis of examination and/or Investigation, in my opinion death occurred at <br />the time, date and place and due to the causes) Meted. (Signature and Tale) <br />26b. WAS CONSENT GRANTED? <br />Not Applicable if 26a Is NO ❑ YES <br />28b. DATE FILED BY REGISTRAR(MO:r, "Day, Yr.) <br />April 20, 2017 <br />O <br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print <br />Adarrl:. Brost, MD,: 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803: <br />i <br />