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d&11A, M. .. , dt4 n�. , � . �. 16.. '.0,40#44193s.,0 M. 1.. ur AA % Marll W K J 7. 0 CC W v E U -� 8 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 12/18/2017 LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Jay Curtis Stoddard 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Eustis, Nebraska SOCIAL SECURITY NUMBER 506 -28 -8144 812. FACILITY -NAME (If not Institution, give street and number) Good Samaritan Society-Grand Island Village 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 IMMEDIATE CAUSE (Final disease or condition resulting in death, Sew ertiaily list ceirditiods, any, #eading to the ause listed on linear 2d,INJURY. AT' WORK _ ❑..YES ❑NO 9a. RESIDENCE -STATE • Nebraska 7 9d. STREET AND NUMBER • 1810 W. Charles Street w • E10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Fred Stoddard 13: EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) NO 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other(Specify) Enter the UNDERLYING CAUSE ttlisedee orinjurythet )nhiated the events resulting: in death) LAST 22a. DATE OF INJURY (Mo., Day, Yr.) . DATE OF DEATH (Mo„ Day, Yr.) December 12,2017 23b. DATE SIGNED (Mo., Day, Yr.) December 13, 2017 STATE OF NEBRASKA - DEPARTMENT OF HEALTH? AND HUMAN SERVICES CERTIFICATE OF DEATH 9b, COUNTY Hall 16a, EMBALMER- SIGNATURE Stacie L. Ruiz 16d. CEMETERY, CREMATORY OR OTHER LOCATION Ord City Cemetery 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street. Grand Island. Nebraska 18. PART I. Enter the l oak, of events -- diseases, injuries, or complications -that directly caused the death. 00 NOT enter temrinal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line.' Add additional lines if necessary. IMMEDIATE CAUSE: a)Alzheimers Dementia DUE TO, OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: c) 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. Coronary Artery Disease, Diabetes Mellitus Type 2, Hypertension, Hypertipidemia 0. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnam, but pregnant within 42 days of death ❑ t o ,, gI a,:t but preyraM 43 dais to 1 year before dee!h ❑ Unknown if)srpgneM wiahla the past year 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. o 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) Jav C• Anderson, MD 23c. TIME OF DEATH 06:43 AM 20 .800443 5a. AGE - Last Birthday (Yrs.) 87 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 10b. NAME OF SPOUSE (First, Middle, Dorothy Jean Hosek 14a. INFORMANT -NAME Dorothy Jean Stoddard CAUSE OF DEATH (See instructionnand examples) 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined CITY /TOWN 8c. CITY OR TOWN Grand Island MOS. 26a. HAS ORGAN OR TISSUE DONATION BEE] 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES El NO • ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 b. UNDER :1 YEAR 1 12. MOTHER'S -NAME (First, Amelia Hansen 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) DAYS STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 9e. APT. NO. 1495 8d. COUNTY OF DEATH Hall 16b. LICENSE NO. CITY / TOWN Ord 2. SEX Male 5c. UNDER 1 DAY HOURS 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger 0 Pedestrian Otbertspecifyl STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) MINS. OTHER ® Nursing Home /LTC Dace ;erf'' Hots ❑ Other (Specify) 9f. ZIP CODE 68803 )6 Cafe Last, Suffix) If wife, give maiden name Middle, Maiden Surname) onset to 3. DATE OF DEATH (Mo., Day, Yr.) December 12, 2017 6. DATE OF BIRTH (Mo., Day, Yi February 12, 1930 ❑ YES NO ❑ Hospice Facility 1 9g. INSIDE CITY LIMITS' ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENTr Wife 16c. DATE (Mo., Oay, Yr.) December 16, 2017 STATE Nebraska 17b. Zip Code 68801 A PPROXtMATE'1NT£RVAta onset to death Years Onset to death onset to dead 1 1 5 79 4 ? 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 21c. WAS AN AUTOPSY PERFORMED? 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 24b. TIME OF DEATH 24d. TIME PRONOUNCED 0 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 Title) CONSIDERED?' 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 28b. DATE FILED BY REGISTRAR (M0., Day, Yr. December 14, 2017 ZIP CODE D 0 NO