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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
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<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
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<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Adarrl:. Brost, MD,: 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803:
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