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),?At , "x '°'AZ STATE OF NEBRASKA WHEN ti 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 2/9/2018 LINCOLN, NEBRASKA 2018014'75 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 4. CITY:AN STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Fremont, Nebraska 7. SOCIAL SECURITY NUMBER 505 -46 -4520 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Jerry Wayne Sevy 8b. FACILITY -NAME Of not Institution, give street and number) ce • 8c. CITY OR TOWN OF DEATH (Include Zip Code) ° 68803 • CHI Health St. Francis Grand Island 9a. RESIDENCE -STATE Nebraska 9d. STREET AND'NUMBER 415 N. Waldo 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated ❑ Widowed E Divorced ❑ Unknown 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Urk.) No 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation E Cremation ❑ Entombment ❑ Removal ❑ other (Specify) 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 line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting in death) Sequentially list conditions, if any leading to the.oause listed Enter the UNDERLYING CAUSE (disease or injury that miriated the events resuhing death) LAST r>; tit ty., 20. IF FEMALE: • ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death 0 Not pregnant, bm pregnant. 43 days to 1 year before death © Unknown if pregnant within the past year W L) E 22a. DATE OF INJURY (Mo., Day, Yr.) 0 i $ 22d.1NJURY M [}YES [j ND 1 23a. DATE OF DEATH (Mo., Day, Yr.) January 29: 2018 Trad. Penner, ; 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Not Embalmed DUE TO, OR AS A CONSEQUENCE OF: b)Aspiration 22b. TIME OF INJURY 23b DATE SIGHED (Mc., D ?,v,'fr.) 1 23c. TIME OF DEATH February 2, 2018 1 12:05 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) . AGE - Last Birthday CA's.) 77 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 8a. PLACE OF DEATH HOSPITAL ® Inpatient © ER/Outpatient ❑ DOA 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY E UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Traci Penner, APRN, 2621 W Faidley Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE 110- / � , zA- 5b. UNDER 1 YEAR MOS. 9C. CITY OR TOWN Grand ;- island DAYS HOURS 9e. APT. NO. 2. SEX Male 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger 0 Pedestrian ❑ Other (Specify) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES NO 5c. UNDER 1 DAY MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) Bd CO UNTY OF DEATH 1 Hall 9f. ZIP CODE 68803 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name 11. FATHER'S -NAME (First, Middle, Last, Suffix) Durward H Sevy 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mabel J Ludvigsen 14a. INFORMANT-NAME Julie Spires 3 b. LICENSE NO. 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street. Grand Island. Nebraska for Central Nebraska Cremation & Mortuary Service. 609 Front Street. PO Box 280, Gibbon, Nebraska 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 3. DATE OF DEATH (Mo., Day, Yr.) January 29, 2018 November 13, 1940 6. DATE OF BIRTH (Mo, Day, Yr.) 9g. IN CITY LIMITS" ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Significant Other ... . 16c. DATE (Mo., Day, Yr.) February 1, 2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE Nebraska 1713. Zip Cods 68801 68840 CAUSE OF DEATH (See instructions and examples) APPROXIMATE INTERVAL onset todeath 12 Hours onset tp;deth 72 Hours Hospice Facility DUE TO, OR AS A CONSEQUENCE OF: c) Encephalopathy onset to death 7 Days DUE TO, OR AS A CONSEQUENCE OF: d)Metastatic Brain Cancer onset to death >1 year 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? 0 YES gi NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ENO 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) 22e, DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH r 24c. PRONOUNCED DEAD (MO., Day, Yr. 24d. TIME PRONOUNCED DEAD , a ¢ Z g LO Z 2z Iq- U 8 C 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) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES LJ NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.} I February 2, 2018 j STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES