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STATE OF NEBRASKA '.`t t 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 201800192 10/4/2016 LINCOLN NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Gerhard Jacob Eyten 4. CITY ANOSTATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Juniatar Nebraska 7. SOCIAL SECURITY NUMBER 507 -36 -1417 b. FACILITY -NAME (if not Institution, give street and number) Edt#ewood Vista Grand Island 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE 9b. COUNTY Nebraska Hall 9d. STREET AND NUMBER 403 W. Cedar St. lea. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married ❑:Married, but separated 0 Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Jacob Siebelt Eyten EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME (Yes, No, or Unk.) Yes 09/02/1952- 08/05/1954 Janyce Rae Eyten', 5. METHOD OF DISPOSITION 16a. EMBALMER - SIGNATURE E Burial ❑ Donation ❑ Cremation ❑Entombment ❑ Removal ❑ Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island. Nebraska 1 a, 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, orventricatar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause '. on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting ill death) .. any, leading td the i ause )iited< on line n.._ • _.... Enter the UNDERLYING CAUSE {disease or injury . that initiated the events resbhinQ fn death) LAST 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Dementia 20. I ❑ Net pregnant: vithirt past Year ❑. Pregnant at time of death Notpregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant43 days to 1 year before death ❑ t ,known If pregnant Withuithe past year 22a. DATE OF INJURY (Mo., Day, Yr.) 23d. INJURY AYWQRK ?:: I ❑ YE ❑ NO S 22f. LOCATION OF INJURY STREET &NUMBER, APT.NO. S a v STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Daniel D Naranjo 16d. CEMETERY, CREMATORY OR OTHER LOCATION Cedarview Cemetery DUE TO, OR AS A CONSEQUENCE OF: 5 /Metastatic Colon Cancer DUE TO OR AS A CONSEQUENCE OF: C) DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 5a. AGE - Last Birthday 5b. UNDER .1 YEAR (Yrs.) 84 CAUSE OF DEATH (See instructions and examples) 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Couldinet be determined 23a. DATE OF OE. (Mo., Day, Yr.) t ep ern b er :24 20 ?'ti r3 TE SICNt~A (Mc, Cie" Yr.! • 1 2 ,, ny,r_ OF nFATW September 28, 28, 2016 07:15 PM 35. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Jennifer G., Brown, MD 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) CITY/TOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 5. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ED NO ❑ PROBABLY ❑ UNKNOWN ❑ YES E NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Jennifer L Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 i a. REGISTRAR'S SIGNATURE. 74 MOS. Sc. CITY OR TOWN. Doniphan DAYS 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient n DOA 9e. APT. NO. STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 2. SEX Male 16b, LICENSE NO. 1071 5c. UNDER 1 DAY HOURS OTHER ❑ Nursing Home /LTC 0 Hospice Facility ❑ Decedent's Home E Other (SpecifyASSISTED -1 8d. COUNTY OF DEATH Hall 1Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden na Janyce Rae Kingston 1 12. MOTHER'S-NAME (First, Middle, Reka Hilda Bunken CITY / TOWN Doniphan 24a. DATE SIGNED (Mo., Day, Yr.) MINS. 9f. ZIP CODE 68832 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian Other (SpecltY) STATE ate 3. DATE OF DEATH (Mo., Day, Yr.) September 24, 2016 6. DATE OF BIRTH (Mo., Day, Yr. March 3, 1932 Maiden Surname) 24b. TIME OF DEATH onset tot . tath < 1 Molth 9g. INS(DE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr.) September 29, 2016 17b. Zip Code 68801 onset to death > 1 Day STATE Nebraska APPROXIMATEiINTEttVA onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? YES ENO 21c. WAS AN AUTOPSY PERFORMED? ". ❑ YES E NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ' ❑ YES ❑ NO ZIP C pRONt'ti1NCF I t?EAD (Mo.. Day, Yr.), 24d. TIME PRONnUNr=ED DEAD • 24e. On the basis of examination and/or investiga ion, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Tide) 26b. WAS CONSENT GRANTED? Not Applicable if 26a 1s NO ❑ YES ❑ 28b. DATE FILED BY REGISTRAR (Mo., Pay Yr. September 29, 2016 CD