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k kOkit I °I 6 ,.,.: >.'S ...,.I t VtX�y r �� 1, , ii/ 1 v , U, v V � 4,4 STATE OF NEBRASKA Ittirra ) d / C I SVAIU A@t - xa ■ t a a an r x3za,�`�1L tt'Ser 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 12/8/2017 LINCOLN, NEBRASKA 201800169 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH atop STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES re w U 1. DECEDENTS -NAME (First, Middle, Last, Suffix) James Charles lbach 4, CITYIAND STATE QR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Overton, Nebraska 7. SOCIAL SECURITY NUMBER 505 -54 -5054 8b. FACILITY -NAME (if trot Institution, give street and number) Veterans Affairs Medical Center 9a. RESIDENCE-STATE Nebraska 5a. AGE - Last Birthday (Yrs.) 74 9b. COUNTY Hall 5b. UNDER ,1 YEAR MOS. 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island. 68803 9d. STREETAN(NUMBER 2014 N Broadwell 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated; ❑ Widowed ❑ Divorced ❑ Unknown 0 Q' 13 EVER IN U.S. .ARMED FORCES? Give dates of service if Yes. 8 (Yes, No, or Unk.) Yes : 02/12/1969- 09/18/1970 11. FATHER S -NAME (First, Middle, Last, Suffix) Norris L lbach 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Irene Rose Rollins 15. METHOD OF DISPOSITION 16a. EMBALMER- SIGNATURE G ❑ Burial 0 Donation on Not Embalmed ❑ Cremation ❑ Entombment ❑ Removal ❑ Other(Specify) in dea th) Seyue tiallyliat conditions, if any, to the cause Eisred on line a • DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease orinjury:that indtatind re -tilting in death) c (1) 2 2d. INJURY AT WORK? ❑YES NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. . DATE OF DEATH (Mo., Day, Yr.) Movembes 24, 2017 3b. DATE SIeNED (Mo., Day, Yr.) November 28, 2017 23c. TIME OF DEATH 09:15 AM 3d. To the best of my knowledge, death occurred at the time date and place and due to the cause(s) stated. (Signature and Title) Shawn $. Lawrence, MD 28a. REGISTRAR'S SIGNATURE 10b, NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Danelle Schwieger 14a. INFORMANT -NAME Danelle lbach Coeviit^- 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home/LTC ❑ Decedent's Home ❑ Other (Specify) 0 Hospice Facility 9c, CITY OR TOWN Grand Island DAYS 16b. LICENSE NO. 2. SEX Male 5c. UNDER 1 DAY HOURS 9e. APT. NO. MINS. 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68803 3. DATE OF DEATH (Mo., Day, Yr.) November 24, 2017 6. DATE OF BIRTH (Mo., D May 8, 1943 9g. INSIDE CITY LIMITS ❑ YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day Yr.) November 28,2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Memorial Park Crematory CITY / TOWN Grand Island STATE Nebraska 17a. FUNERAL W)ME NAME AND MA LING ADDRESS (Street, City or Town, State) Livinaston - Sondermann Funeral Home. 601 N. Webb Road. Grand Island, Nebraska 1 1711.21p Coder 68803 CAUSE OF DEATH (See instructions and examples) APPROXIMATE' INTERVAL onset to death Months 18. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one Cause on a IineiAdd additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a)Acute Myelomonocytic Leukemia disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF: b)Chronic Myelomonocytic Anemia onset to!dea Years onset to death Me events LAST _ • 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 1. Chronic Obstructive Pulmonary Disease, Hypertension, Atherosclerosis Of Coronary Arteries 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES Ea NO 20. IF FEMALE: r ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Notpregnant, but pregnant within 42 days of death ❑ Not pregnant, but ptagnant43 days to 1 year before death ❑ Unknown if piegnanf within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could ndt be determined 21a= IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger Pedestrian ❑ Outer (Specify) 21c. WAS AN AUTOPSY PERFORMED ? :; El YES ED NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 122c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED CITY /TOWN � z'g 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Shawn S. Lawrence MD, 223 South E St, Broken Bow, Nebraska, 68822 z s 0 0 g rc v '6 0 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) STATE ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUN 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) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED 26b. WAS CONSENT GRANTED? YES ❑ NO ® PROBABLY ❑ UNKNOWN ❑ YES Ea NO Not Applicable if 26a is NO ❑. YES ❑ NO 28b. DATE FILED BY REGISTRAR(MO., Day Yr.) : December 8, 2017