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STATE OF NEBRASKA a W IT 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 11/16/2017 COLN, NEBRASKA covisi STANLEY S. OPER 201801352 ASS S ANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Allan Ray Jaeger 4. CITY' AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Beatrice, Nebraska 7. SOCIAL SECURITY NUMBER 505 -54 -3390 8b. FACILITY -NAME (If not Institution, give street and number) 209 West Bartelt Avenue 8c. CITY OR TOWN OF DEATH (Include Zip Code) Doniphan 68832 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 209 West Bartelt Avenue 10a. 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 (Jnk,) No 15. METHOD OF DISPOSITION ❑ Burial •❑ Donation ® Cremation ❑ Entombment ❑ Ret0Oval :❑ Otll:er:;(Specify) 23a. DATE OF::DEATH (Mo., Day, Yr.) 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH U 2 uu ¢ O 3d. To the best of my knowledge, death occurred at the time, date and place c and due to the cause(s) stated. (Signature and Title) 2 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES(} NO ❑ PROBABLY ❑ UNKNOWN I 28a, REGISTRAR'S SIGNATURE A - a ."- 5a. AGE - Last Birthday (Yrs.) 75 9b. COUNTY Hall MOS. 16a. EMBALMER- SIGNATURE Not Embalmed 5b. UNDER 1 YEAR 9e. APT. NO. DAYS 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES I NO 2. SEX Male Sc. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) Found November 6, 2017 6. DATE OF BIRTH (Mo., ;Day, Yr.) September 20, 1942 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 Sc. CITY OR TOWN Doniphan 9f. ZIP CODE 68832 9g. INSIDE CITYLIMITS El YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name LaDonna May Sandoe 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Edna Mae Wandersee Otto Carl Jaeger 14a. INFORMANT - NAME Jeffr Allan Jaeger 16b. LICENSE NO. 14b. RELATIONSHIP TO DECEDENT Son 16c. DATE (Mo., Day, Yr.) November 7, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE ebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska 17b. Zip' Cod 68801 CAUSE OF DEATH (See instructions. and examples) 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, teapiratory 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) Myocardial Infarction disease or condition resulting • APPROXIMATE I NTERVAL: onset to •death Minutes Sequ,,lttially list conditions, it any, tepding to the cause listed on line �a Enter the UNDERLYING CAUSE (disease oi' injury, 11141 initiated:: DUE TO, OR AS A CONSEQUENCE OF: b) Heart Disease onset to death Years DUE TO, OR AS A CONSEQUENCE OF: C) Diabetes onset to death Years the events resuhillf in death VAST 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. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES I: NO 20. IFFEMALE El Not pregnant Within:Oat : year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death •gn ❑ Not pream, put pregnant`43 days to 1 year before death ❑ Unknown if pregnant wiedit the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other! (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO : 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY 22d. INJURY ATWORK? ❑YE5 ❑NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE 24a. DATE SIGNED (Mo., Day, Yr.) November 9, 2017 24b. TIME OF DEATH Unknown a 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD a z November 6, 2017 10:12 AM 8 z O 24e. On the basis of examination and /or investigation, in my opinion death occurred at .8 S p the time, date and place and due to the cause(s) stated. (Signature and Title) 12 C.: a Joseph E. Dobesh, 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 Joseph E. Dobesh, Deputy County Attorney, 231 S Locust St, Grand Island, Nebraska, 68802 28b. DATE FILED BY REGISTRAR (MO.,pay, Yr.) November 13, 2017