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STATE OF NEBRASKA
<br />2 W
<br />r 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH t V 24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />74 d
<br />v z September 15, 2016 02:13 PM o E a > o
<br />a O 3d. T the best of my knowledge, death occurred at the time, date and place w
<br />u • and due to the cause(s) stated. (Signature and Title) .5 2 2
<br />l
<br />K
<br />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 />9/20/2016
<br />LINCOLN, NEBRASKA
<br />201707300
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />L i j ifer I
<br />Jennifer MD
<br />25. DID TOBACCO USE:. CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN
<br />[1 YES ❑ NO 0 PROBABLY ❑ UNKNOWN ❑ YES
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jennifer King, MD, 2011 W Clarice St, Doniphan, Nebraska, 68832
<br />28a ,REGISTRARS SIGNATURE
<br />O c
<br />IJ
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<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 cause(s) stated. (Signature and Title)
<br />OR TISSUE DONATION BEEN CONSIDERED?
<br />10 NO
<br />at
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<br />ZIP C
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Richard Lee Geist Sr
<br />4, CITY!AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island
<br />Ne
<br />braska
<br />7. SOCIAL SECURITY NUMBER
<br />507 -24 -4668
<br />8b. FACILITY - NAME (ff not Institution, give street and number)
<br />2225 Viiu ng',Rost.;
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />86
<br />MOS.
<br />9b. COUNTY
<br />Hall
<br />Bb. UNDER 1 YEAR
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />ER/Outpatient
<br />❑ DOA
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />>3c. CITY OR TOWN
<br />Grand Island'
<br />9d. STREET AND `NUMBER
<br />2225 Viking Road
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑Married, but separated :. ❑ Widowed ❑ Divorced ❑ Unknown
<br />S -NAME (First, Middle, Last, Suffix)
<br />Geist
<br />07 Jacob
<br />_ m
<br />E 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, orUnk.)NO
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />0 Removal Q Other (Specify)
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Alzheimers Dementia
<br />disease or condition resulting
<br />;'p death).
<br />Sequentially !1st conditions if b)
<br />any, ('ceding to Met ause listed .
<br />on line's. -
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE : c)
<br />;Idiseasaorinjury that Initiated
<br />the eyents tesuntng:m deaths DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST :d).
<br />20.1E FEMALE: ..
<br />0 Not pregnant Within past year
<br />❑ Pregnant at time of death
<br />❑ Nat pregnant, but pregnant within 42 days of death
<br />Q Not pregnant, hid pregnant43 days to 1 year before death
<br />❑ I,lnknoom N pregnamwithitjthe past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />a 22d, INJURY ATWORK?
<br />• 1,••• [� YES Q NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />23a. DATE OF :DEATH (Mo., Day, Yr.)
<br />September12, 2016
<br />16a. EMBALMER-SIGNATURE
<br />Chris McCoy
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />22b. TIME OF INJURY
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could net be determined
<br />22c. PLACE OF INJURY -At home,
<br />CITY/TOWN
<br />DAYS
<br />9e. APT. NO.
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Middle, Last, Suffix) If wife, give maiden name
<br />10b. NAME OF SPOUSE (First,
<br />Barbara Richeal
<br />f 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Marie Adler
<br />14a. INFORMANT -NAME
<br />Richard Geist Jr
<br />16b. LICENSE NO.
<br />1191
<br />Grand Island
<br />17a. FUNERAL MOMS NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel f=uneral Horne, 1123 W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions, and examples)
<br />14. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT entettemtinat events such as cardiac arrest,
<br />respiratory atreSt, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line.: Add additional lines d necessary.
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Chronic obstructive pulmonary disease, Lung Mass not Biopsied)
<br />21b. IF TRANSPORTATION INJURY
<br />0 Dnver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />arm, street, factory, office building, construction site, etc, (Specify)
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />MINS.
<br />OTHER ❑ Nursing Home /LTC
<br />® Decedent's Horne
<br />❑ Other(Specify)
<br />9f. ZIP CODE
<br />68803
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />September 12, 2016
<br />6. DATE OF BIRTH (Mo., 'Day, Yr,);,
<br />June 7, 1930
<br />❑ Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />Ei YES ❑ NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />16c. DATE (Mo., Day, Yr.)
<br />September 16, 2016
<br />APP
<br />❑ YES ❑ NO
<br />24b. TIME OF D
<br />STATE
<br />Nebraska
<br />17b, zip Code
<br />68801
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES g ND
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABL
<br />TO COMPLETE CAUSE OF DEATH?
<br />OXIMATE INTERVAL
<br />onset to death
<br />> 1 Yr
<br />onset to death
<br />EATH
<br />24d. TIME PRONOUNCED DEAD
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />28b. DATE FILED BY REGISTRAR (MO., Day, fr.)
<br />September 16, 2016
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