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AWN& erg i'. ff 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Stephen Charles Luebbe 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 506 -68 -1779 b. FACILITY -NAME (If not Institution, give street and number) ii Good Samaritan Society - Grand Island Village W 8c. CITY OR TOWN OF DEATH (Include Zip Code) • Grand Island 68803 4 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 2608 Sothman Dr. 9b. COUNTY Hall 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 0 15. METHOD Of DISPOSITION ❑ Burial Donation ® Cremation ❑ Entombment ❑ Removal ❑ Other(Specify) E 13. EVER IN U.S.; ARMED FORCES? Give dates of service if Yes. 3 (Yes, No, or Unk.) No 5a. AGE - Last Birthday (Yrs.) 69 5b. UNDER 1 YEAR MOS. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island DAYS 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. OTHER ® Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 10b. NAME OF SPOUSE (First, ; Middle, Last, Suffix) If wife, give maiden name Mary Margaret Buhrman 11. FATHER'S -NAME :(First, Middle, Last, Suffix) Arthur Luebbe 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ruby Thesenvitz 14a. INFORMANT -NAME Mary Margaret Luebbe 16a. EMBALMER-SIGNATURE Not Embalmed 46b. LICENSE NO. 175. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island, Nebraska 3. DATE OF DEATH (Mo., Day, Yr.) December 18, 2017 6. DATE OF BIRTH (MO:, Day, Yr December 4, 48 ❑ Hospice Facility 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY )MITS' ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr) December 22, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon STATE Nebraska 17b zip Code. 68801 0. E 0 u 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 12/26/2017 LINCOLN, NEBRASKA CAUSE OF DEATH (See instructionsrd examples 18. PART 1. Entettfie chain of events- -diseases, injuries, or complications -that directly caused the death. DONOT 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 lira. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final aiseaso or common resulting 1 1n 408111) DUE TO, OR AS A CONSEQUENCE OF: seguentlatly list conditions, if b) any leading to Me hated on line 8. Enter the UNDERLYING CAUSE tdtseae et injury that fantasia the events resulrfng in death} ?::, LAST 18, PART II.OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Chronic Obstructive Pulmonary Disease, Head And Neck Cancer,hypertension !a't. 20. IF:FEMALE: • • 0 Not pregnant within past year W ❑ Pregnant at time of death U Not pregnant, but pregnant within 42 days of death • ❑ Not ptagnattt,.DU1 pregnant 43 days to 1 year before death ❑ tlnkaown if pregnam within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT .WORK? 0 YES 0 NO 8 g t- W U a i 0 3a. DATE OF DEATH (Mo., Day, Yr.) December 18, 2017 STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH a) Metastatic Adenocarcinoma Lung DUE TO, OR AS A CONSEQUENCE OF: C) DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 3b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH December 20, 2017 09:10 AM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the causeis) stated. (Signature and Title) Ryaff D, Crouch, DO 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 2 YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 201801984 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not no determined CITYITOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ]NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ryan D, Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803 I28a. REG )STRAR'S S)GNATURE 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24c. rF`. 211. IF TRANSPORTATION 0 Driver /Operator ❑ Passenger 0 Pedestrian ❑ Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) INJURY j STANLEY COOPER ASSISTA to STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES APPROXIMATE INTE onset to death 2 Years onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 21c. WAS AN AUTOPSY3'ERFORMED?? ❑ YES NO STATE ZIP CODE 24b. TIME OF DEATH NOJNC DE. ^. (:1:a., Day, Yr.)■ 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 0 YES ❑ - - NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 20, 2017 21d. WERE AUTOPSY FIN DINGS AVAILABLE TO COMPLETE CAUSE OF :DEATH? ❑ YES ❑i N0 CD C