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4SW- Q. A 9 .64 x:f.■ r " �c...� STATE OF NEBRASKA t6L� r,��?anw8, ° fd 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 4/27/2017 LINCOLN, NEBRASKA 201705833 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES PART t Peter f1i? rh�ie n o _.di <exe r...< n. R^ t407 - _.. cardiac a: re4, re piratory arrest, or •yentri filar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Tine Add additional lines if necessary. • IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Sepsis Syndrome disease or condition resulting C. 4. CITY AND STATE QR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 0 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Richard Allen Epperly Minneapolis, Minnesota 7. SOCIAL SECURITY NUMBER 470 -32 -127.9 8b. FACILITY -NAME (If not institution, give street and number) CH) Health St Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island G8803 9a. RESIDENCE.-STATE Nebraska 9d. STREET AND NU MBER 504 East 17th Street 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S•NAME jFirst, Middle, Last, Suffix) Edward S T Epperly l 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Alice Elizabeth Bailey 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) }res 08/21/1953-08/20/1956 15. METHOD OFDISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal ';❑ Other (Specify) 5a. AGE - Last Birthday (Yrs.) 83 9b. COUNTY Hall 5b. UNDER 1 YEAR MOS. 1 DAYS HOURS 2. SEX Male 5c. UNDER 1 DAY MINS. 8a. PLACE OF DEATH HOSPITAL © Inpatient ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 9c. CITY OR TOWN Grand Island 9e. APT. NO. 9f. ZIP CODE 68801 10b. NAME OF. SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Julia M Thatcher 14a. INFORMANT- NAME :. Julia M Epperly 16a. EMBALMER - SIGNATURE Not Embalmed 8d. COUNTY OF DEATH H�II b. LICENSE NO. 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Howie. 1123 W. 2nd. Grand Island. Nebraska CAUSE OF DEATH (See instructions and examples) 3. DATE OF DEATH (Mo., Day, Yr.) April 19, 2017 6. DATE OF BIRTH (Mod,, Day, Yr.) December 22, 1933 ,> 9g. INSIDE CITY LIMITS Ei YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) April 21, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE Nebraska 17b. Zip Code 68801 APPr(OXIMAlEINTERVAL onset to death 72 Hours in death) SeseeidiaIIyifat ci nditlons, if any, lgading to thecause listed DUE TO, OR AS A CONSEQUENCE OF: b)Acute Peritonitis Enter the UNDERLYING CAUSE :;(disease orinjurythat mniated the events resulbr g m death) LAST's DUE TO, OR AS n CONSEQUENCE OF: c) Acute Diverticulitis Cnr.Ot t0 doCt 10 Days DUE TO, OR AS A CONSEQUENCE OF: d) 18. PARTII. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 20. iF FEMALE: ❑ 'Not gnantwidnn past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death © Not pregnant,.; but pregnant : 43 days to 1 year before death 13 :41,1 7 00 Itpregnantwtthtnthe past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY ATVIORK? 0YES p NO 22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO. 21a. MANNER OF DEATH ▪ Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide 0 Couldnot be determined 22b. TIME OF INJURY 1 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED CITY/TOWN . DATE OF DEATH (Mo., Day, Yr.) April 19, 2117 1 F 23b. DATE SIGNED (Mo., Day, Yr.) u z April 21 2017 23c. TIME OF DEATH 04:35 PM a. 0 3d, To the best of my knowledge, death occurred at the time, date and place 2 and due to the cause(s) stated. (Signature and Title) a Ill s Ryan D. Crouch, DO 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) 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger 0 Pedestrian ❑ Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) onset to death 72 Hours 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES NO 21d. WERE AUTOPSY FINDINGS AVAI TO COMPLETE CAUSE OF DEATH'? ❑YES 0 N STATE ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 126a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED ?' 26b. WAS CONSENT GRANTED? ❑ YES El NO ❑ PROBABLY ❑ UNKNOWN j ❑ YES RI NO I Not Applicable if 26a is NO ❑ YES 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, .:: 28a, REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (MO., Day; Yr.) April 24, 2017 CD CD