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STATE OF NEBRASKA 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 6/13/2017 LINCOLN, NEBRASKA 20180212e STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH tt: U Lu 3, 01 d 3, d E 8 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Jerry Duane Brown 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Lincoln, Nebraska 7. SOCIAL SECURITY NUMBER 505 -40 -5666 8b. FACILITY - NAME )Ifnot •Institution, give street and number) • Good Samaritan Society -Grand Island Village 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 < - 9a. RESIDENCE -STATE Nebraska LL 9d. STREET AND' NUMBER 1711 Lariat Lane 9b. COUNTY Hall 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑Married, but separated; ❑ Widowed ❑ Divorced ❑ Unknown 5a, AGE - Last Birthday (Yrs.) 81 Sb. UNDER 1 YEAR MOS. 1 9c. CITY OR TOWN Grand Island DAYS 9e, APT. NO. 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 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 9f. ZIP CODE 68803 3. DATE OF DEATH (Mo., Day, Yr) May 12, 2017 6. DATE OF BIRTH (Mo Da Yr.);, August 1, 193 5 ' 9g. INSIDE CITY IJM1TSi ® YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Alice Fave Starkey_;' 11. FATHERS-NAME (First, Middle, Last, Suffix) Harry G Brown 12. MOTHERS-NAME (First, I Lula V Badburg Middle, Maiden Surname) 13. EVER. IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 03/08/1954-11/26/1957 15. METHOD OF DISPOSMON ❑ Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Tracey Dietz 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Westlawn Memorial Park Cemetery Grand Island STATE Nebraska 17a. FUNERAL H '1ME NAME AND MA LING ADDRESS (Street, City or Town, State)'' Apfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chant of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventr)cular 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) Acute Respiratory Failure disease or condition resulting APPROXIMATE INT Onset to death Minutes DUE TO, OR AS A CONSEQUENCE OF: b)Chronic Obstructive Pulmonary Dise onset to death Several Years in death) Sequentially list coitid tieing, if any, Leading to the Cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death N/A i Enter the UNDERLYING CAUSE c) N/A „(disea$e.ogjnjury that initiated,,, the events resuhmg to death) 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY ❑YES QNO 23a. DATE OF DEATH (Mo., Day, Yr.) MaY12,2017 23b. DATE SIGNED (Mo., Day, Yr.) May 22. 2017 DUE TO, OR AS A CONSEQUENCE OF: d)N /A 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Coronary Artery Disease 20. IF FEMALE: ❑ Not pregnanttivlthin past year ❑ Pregnant at time of death 0 Not pregnant, but pregnant within 42 days of death ❑ Nct pregnant, byt pregnant 43 days to 1 year before death • ❑ Unknown if ptegnantwnhin the past year 22b. TIME OF INJURY 21a. MANNER OP DEATH ® Natural ❑ Homicide 0 Accident ❑ Pending Investigation ❑ Suicide ❑ Could Itwit be determined 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 2Sa. REGISTRAR'S SIGNATURE 23c. TIME OF DEATH 12:00 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) Thornas F. Werner, MD 5. DtD TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print 14a. INFORMANT -NAME Alice Fave Brown 26a. HAS ORGAN ❑ YES 16b, LICENSE NO. 1328 21b. IF TRANSPORTATION INJURY Driver /Operator ❑ Passenger ❑ Pedestrian D Other.( Specify) 24e. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) OR TISSUE DONATION BEEN'sCONSIDERED? NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) 7 May 16, 2017 17b. zlpCode 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES IJ NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ONO 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) 24b. TIME OF DEATH 24d. TIME PRONOUNCE 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 Tide) 26b. WAS CONSENT GRANTED/ Not Applicable if 26a is NO ❑ YES ❑ NO Thomas F. Werner, MD, 810 North Diers Avenue, Grand Island, Nebraska, 68803 28b. DATE FILED BY REGISTRAR (MO,, .Day, Yr.) May 23, 2017