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it! SA 1 'u e at kV Fi .; &AO :, .it ,N ,M,41 inWERVX;;ZinetWiiretelt STATE OF NEBRASKA 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 VITAL RECORDS DATE OF ISSUANCE 6/12/2017 LINCOLN, NEBRASKA 201705776 STATE OF NEBRASKA - DEPARTMENT OF HEALTH! AND HUMAN SERVICES CERTIFICATE OF DEATH ate STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 0 U Et 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 g 9a. RESIDENCE•STATE 9b. COUNTY Z zw Nebraska Hall U- .o 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Ervin Lawrence Luth Jr 4. CITY! AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Aida, Nebra ka 7. SOCIAL SECURITY NUMBER 508 -40 -1102 6b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 9d. STREET AND NUMBER 2403 W Division e. APT. NO. 9f. ZIP CODE 68803 1 9g. INSIDE CITY LIMITS" ® YES ❑ NO 1Oa. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated! ❑ Widowed ❑ Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Sharon Lee Carson 11. FATHER'S -NAME (First, Middle, Last, Suffix) Ervin Lawrence Luth Sr 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ella Kroeger 12. EVER IN U.S.:ARMED:FORCES? Give dates of service if Yes. (Yes No or unto No 15. METHOD OP DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal .❑ Other {Specify) Enter the UNDERLYING CAUSE (disea ;a of injuN dfu initiated.:;. the events resulting in deethl LAST:: 22a. DATE OF INJURY (Mo., Day, Yr.) May 27, 2017 22d, [(JURY AT WORK? k]( YES ❑ NO 23a. DATE OF DEATH (Mo., Day, Yr.) 23b. DATE SIGNED (Mo., Day, Yr.) 16a. EMBALMER - SIGNATURE Laurie D. Sheffield 20. IF FEMALE: ❑ Not pregnantwith.n past year 0 Pregnant at time of death ❑ Not pregnant,:put pregnant within 42 days of death ❑ Net pregnant, nut pregnant:+43 days to 1 year before death ❑ Unknown Lf pregnerltwithihthe past year 22b. TIME OF INJURY 05:04 PM n w J Z b U b Q O 3d. To the best of my knowledge, death occurred at the time, date and place O and due to the cause(s) stated. (Signature and Title) o 23c. TIME OF DEATH 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES EI NO ❑ PROBABLY ❑ UNKNOWN 5a. AGE - Last Birthday (Yrs.) 80 14a. INFORMANT- NAME Sharon Lee Luth 8a. PLACE OF DEATH HOSPITAL 0 Inpatient 21a. MANNER OF DEATH ❑ Natural ❑ Homicide 2 Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 28a. REGISTRAR'S SIGNATURE "6- arrow"- 5c. UNDER 1 DAY HOURS MINS. bb. UNDER 1 YEAR MOS. DAYS ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand! Island 16b, LICENSE NO. 1397 2. SEX Male OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN Grand Island City Cemetery Grand Island STATE Nebraska 17a. FEIN ERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funerat Home. 2929 S. Locust Street. Grand Island, Nebraska 17b ;Zip'Code 68801 CAUSE OF DEATH (See instructns and examples) 16. PART. I. Enter the Chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter temtinai events such as cardiac arrest, respiratory arrest, or verttn4ular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: a) Internal Hemorrhaging IMMEDIATE CAUSE (Final disease or condition resulting in death) any leading to the cause Bated: on fine DUE TO, OR AS A CONSEQUENCE OF: b) Injury APPROXIMATE INTERVAL onset to death Minutes onset to death Minutes= DUE TO, OR AS A CONSEQUENCE OF: c) onset to death 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. 21b. IF TRANSPORTATION INJURY gl Driver /Operator ❑ Passenger 0 Pedestrian 0 Other(Specify) 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) Storage Facility 22e. DESCRIBE HOW INJURY OCCURRED Decedent attempted to move a tractor in storage. In doing so, the tractor made contact with another piece of equipmen noticing the rterertent to fall frnm his positjnn ddutog the trartnt, landing in frnnt of the tire of the trartf'tr STREET & NUMBER, APT.NO. STATE Nebraska 22f. LOCATION OF INJURY - 2107 E. 7th St., Grand Island CITY/TOWN ZIP CODE 68801 24a. DATE SIGNED (Mo., Day, Yr.) June 5, 2017 24c. PRONOUNCED DEAD (Mo., Day, Yr.) May 27, 2017 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES E NO 3. DATE OF DEATH (Mo., Day, Yr.) May 27, 2017 6. DATE OF BIRTH (Mo., Day, Yr.);:.. June 29, 1936 ❑ Hospice Facility 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) June 1, 2017 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ❑ NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? ❑ YES ❑ NO 24b. TIME OF DEATH Approx. 05:30 PM - 24d. TIME PRONOUNCED DEAD 05:30 PM 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) Matthew. C. Boyle, Hall Deputy County Attorney 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Matthew C, Boyle, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 28b. DATE FILED BY REGISTRAR(MO.,>.Day, •Yr.) June 5, 2017