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iftaa� 3i1 #t��ti -. . STATE OF NEBRASKA 55 at mot. 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 20180160 2/23/2018 DATE OF ISSUANCE LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH V' tnu tt1l Y ^ v STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES tY , 0 re t) re C -J Lu 2 w a t 1 Ui 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Clifford Theodore Frymire 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Scotia, Nebraska 7. SOCIAL SECURITY NUMBER 506 -20- 4567 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 68.803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 1709 S. Ingalls Street 105. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S. ARMEP FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 06/17/1944- 07/05/1946 15. METHOD of DISPOSITION ❑ Burial ❑ Donation Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) on line a. 20. IF FEMALE: ❑ Not pregnant within past year 0 Pregnant at time of death ❑ Not pregnant;; but pregnant within 42 days of death Not pregnant,; but pregnant 43 days to 1 year before death 0 unknown if pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d.. INJURY AT WORK? ;❑YES ❑NO 23a. GATE OF DEATH (Mo., Day, Yr.) February '1.0, 2018 .2 1 F 23b DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 6 F ° z February 12, 2018 07:30 AM O 3d. To the best of my knowledge, death occurred at the time, date and place 2 a and due to the cause(s) stated. (signature and Title) o Jay C. Anderson, MD 25.D03 TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES fa NO ❑ PROBABLY ❑ UNKNOWN 2130 .REGISTRAR 16a. EMBALMER - SIGNATURE Gwen K. Hyronemus 22b. TIME OF INJURY S SIGNATURE 5a, AGE - Last Birthday (Yrs.) 92 9b. COUNTY Hall 21a. MANNER OF DEATH ❑ Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined Sb. UNDER 1 YEAR MO DAYS 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ EFUOuitpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? OYES a] NO 8d. COUNTY OF DEATH Hall Sc. CITY OR TOWN Grand Island 9e. APT. NO. 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger Pedestrian Other (Specify) 24a. D ATE SIGNED (Mo., Day, Yr.) 24c PRONOUNCED DEAD (Mo., Day, Yr.) 9f. ZIP CODE 68803 14a. INFORMANT -NAME Virginia Lee Frymire 16b. LICENSE NO. 1448 17a, FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Aofe) Funeral Home. 1123 W. 2nd, Grand Island. Nebraska 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Sepsis, Atrial; Fibrillation, End Stage Renal Disease, Asthma, 3. DATE OF DEATH (Mo., Day, Yr.) February 10, 2018 6. DATE OF BIRTH (Mo., Day, Yr.) November 9, 1925 9g. INSIDE CITY LIMITS ® YES ❑ NO 10b. NAME OF SPOUSE (First, , Middle, Last, Suffix) If wife, give maiden name Virginia Lee Keller 11. FATHER'S -NAME (First, Middle, Last, Suffix) Rea Frymire 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Nellie Elvera Brown 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (MO., Day, Yr'.) February 17,2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE Nebraska 17b.2ip Code 68801 CAUSE OF DEATH. (See instructions and examples) .. r e _. 18. PART]. Enter the chain of events- -diseases, Injuries, or complications -that directly caused the death, DO NOT enter tertnlnal events such as cardiac arrest, tespiratery arrest, of 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) Influenza Pneumonitis disease or condition resulting in death) APPROXIMATE INTERVAL onse t o death Da Sequentially list conditions, if any, Reading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: b) Enter the UNDERLYING CAUSE •(disease or i niu r y tha initiated DUE TO, OR AS A CONSEQUENCE OF: C) onset to death the events resulting in death) LAST DUE TO, OR AS A CONSEQUENCE OF: d) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES s Ir NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES LINO 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 24b. TIME OF DEATH 24d. TIME PRONOUNCED 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 Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO OYES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 February 20, 2018 28b. DATE FILED BY REGISTRAR1MO