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STATE OF NEBRASKA 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 Clop DATE OF ISSUANCE 10/12/2016 LINCOLN, NEBRASKA 20180I06q STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Edward Alan Sargent 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Ord, Nebraska 7. SOCIAL SECURITY NUMBER 508 -4.8 -188.6 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) ._. Grand Island 68803 9a. RESIDENCE -STA' Nebraska 9d. STREET ANDNUMBER 3211 Kennedy Way 20a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated, ❑ Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S.; ARMED; FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 11/27/1961-11/16/1964 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other(Specify) fdiseaseer injury that initiated:., the events resvhing; in death) 20. If FEMALE ❑ Not pregnard within past year 0 Pregnant at time of death ❑ Not pregnant,. but pregnant within. 42 days of death ❑ Not pregnant, bon pregnant 43 days to 1 year before death ❑ Unknown ifpte9nam wdhlt} the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d.;INJURY AT WORK? ❑ YES ❑ NO 22b. TIME OF INJURY 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN 5a. AGE - Last Birthday (Yrs.) 77 9b. COUNTY Hall 16a. EMBALMER- SIGNATURE Gwen K. Hyronemus 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could net be determined 23a. DATE OF DEATH(Mo., Day, Yr.) 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH • a o 2 0 � G 9d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Tale) 28a. REGISTRAR'S SIGNATURE - - o 55. UNDER 1 YEAR MOS. DAYS 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) September 7, 2016 March 7, 1939 6. DATE OF BIRTH (Mo. Da Yr.) 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ® ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 9e. APT. NO. 9f. ZIP CODE 68803 105. NAME OF SPOUSE (First, ; Middle, Last, Suffix) If wife, give maiden name Marlene Schmaderer 11. FATHER'S -NAME (First, Middle, Last, Suffix) Gordon Sargent 12. MOTHER'S-NAME (First, Middle, Maiden Surname) Izola Coons 14a. INFORMANT-NAME Marlene Sargent 16b. LICENSE NO. 1448 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livinaston-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 9g. INSIDE CITY LIMITS` ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day Yr.) September 10, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Westlawn Memorial Park Cemetery Grand Island STATE Nebraska 17b. zip code 68803 CAUSE OF DEATH (See instructions, and examples) .ta. PART I. Enter the Chain of events- -diseases, injuries, or complications -that directly caused Ole 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 line, Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Unsuccessful Cardiopulmonary Resuscitation disease or condition resulting A P P ROXIM ATE ?l N TERVAL' onset to •death i n death) SegUeiitiaiiy fiat co ldmons, d any, leading to the cau hstetl on line - a. DUE TO, OR AS A CONSEQUENCE OF: b)Cardiac Enter the UNDERLYING CAUSE DUE TO, OR AS A CONSEQUENCE OF: C) onset to death DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART 1I. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Coronary Artery Disease 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE 215 +IF TRANSPORTATION INJURY E l Driver /Operator ❑ Passenger ❑ Pedestrian Other (Specify) 245. DATE SIGNED (Mo., Day, Yr.) September 8, 2016 24c. PRONOUNCED DEAD (Mo., Day, Yr.) September 7, 2016 26a. HAS ORGAN OR ❑ YES ISSUE • • ATION BEEN CONSIDERED? 1a NO 19. WAS MEDICAL EXAMINER OR CQRONER CONTACTED? ❑ YES ®Nfl • 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 1)11 NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 24b. TIME OF DEATH 08:04 AM 24d. TIME PRONOUNCED DEAD 08:04 AM 240. On the basis of examination and /or investiga Ion, in my opinion death oCcn'ed at the time, date and place and due to the cause(s) stated. (Signature and Title). Garrett Schroeder, Hall Deputy County Attorney 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Garrett Schroeder, Hall Deputy County Attorney, 231 S. Locust, P • :• 367, Grand Island, Nebraska, 68802 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.);' September 22, 2016