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STATE OF NEBRASKA nn t rY)' g 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Donald Eugene Cogley Sr 4, CITY. AND STATE OH TE RRITORY, OR FOREIGN COUNTRY OF BIRTH Novinger, Missouri 7. SOCIAL SECURITY NUMBER 494 -44 -1928 8b. FACILITY -NAME (If trot Institution, give street and number) CHI Health St. Francis 5a. AGE . Last Birthday (Yrs.) 76 Sb. UNDER 1 YEAR MO DAYS 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE:STATE Nebraska • 9b. COUNTY Hall 9d. STREET AND NUMBER 103 Jupiter St HOURS 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY MINS. 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ Eft/Outpatient ❑ DOA OTHER ❑ Nursing Home/LTC ❑ Decedent's Home ❑ Other (Specify) Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Aida 9f. ZIP CODE 68810 3. DATE OF DEATH (Mo., Day, Yr.) January 18, 2017 6. DATE OF BIRTH (Mo., Day, Yr) November 20, 1940 9g. INSIDE CITY LtMITS< 0 YES ❑ NO 1>* 0 re (-3 W el re LL 1 1 , 00. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 0./Earried, Outsepaiaieu )J widowed ❑ Lre,31,.aJ ❑ n:: o::.: 2 1. FATHER'S -NAME (First, Middle, Last, Suffix) John Francis Cooley 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unit.) NO 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ ;❑ Other (Specify) 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livingston- Sondermann Funeral Home, 601 N. Webb Road, Grand Island. Nebraska 8: PART I. Enter the chain of eveas- - diseases, injuries, or complications -that directly caused the death, DO NOT enter terminal events such as cardiac arrest, respiratery etret, oryentricular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Pneumonia disease or condition resulting alit) Sequentially bet Cgnd(tiona. N any, leading to the Cause listed on sine a. Enter the UNDERLYING CAUSE Laiseaae Or Injury that initiated:.. the events resulting in death) LAST :::. 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. 0. IF: FtrMALE: ❑ Not pregnant Within past year . Pregnant at time of death Not pregnant ,..but pregnant within 42 days of death ❑ Not pregnatt, <bdt pregnant 43 days to 1 year before death ❑ llnknewn itpragnant eirhinihe past year S 2d. INJURY AT;WQR ?' ❑YES ❑NO..:,: . LOCATION OF INJURY - STREET & NUMBER, APT.NO. J Z 0 et 0 3d. To the best of my knowledge., death occurred at the time, date and place r1 g' and due to the cause(s) stated. (Signature and Title) WHEN MS 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 2/7/2017 LINCOLN, NEBRASKA 23b. DATE SIGNED (Mo., Day, Yr.) January 20, 2017 Kenneth Vettel, MD STANLEY S. OOPER 201801650 ASS STANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH! AND HUMAN SERVICES CERTIFICATE OF DEATH 14a. INFORMANT -NAME Janice Cooley 16a. EMBALMER- SIGNATURE Matthew T. Myers 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Westlawn Memorial Park Cemetery DUE TO, OR AS A CONSEQUENCE OF: b) End Stage Chronic Obstructive Pulmonary Disease DUE TO, OR AS A CONSEQUENCE OF: C) DUE TO, OR AS A CONSEQUENCE OF: d) 22e, DESCRIBE HOW INJURY OCCURRED 1 . DATE QF DEATH (Mo., Day, Yr.) January 18 2017 CAUSE OF DEATH (See instructions and examples) 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigatlo(1 ❑ Suicide ❑ Could not be detemNned 23c. TIME OF DEATH 11:28 AM lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name ,.ULniCe hi -•Ian 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Sadie Darnell CITY/TOWN 28a. REGISTRAR'S SIGNATURE 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 27: NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Kenneth Vettel, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 16b LICENSE NO. 1411 Grand Island 21 b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES 12] NO ate 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) January 23, 2017 STATE Nebraska 1 17b. Zip Code 68803 APPROXIMATaINTERVAL: : onset to death Days onset to death Years 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 1 NO 21c. WAS AN AUTOPSY PERFORMED ? :: ❑ YES 11 NO 21d. WERE AUTOPSY ENDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ID YES 0 N 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 122c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUN D EAD :> 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Tole) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr. January 24, 2017