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To be completed by: CERTIFIER I I To be completed/verified by: FUNERAL DIRECTOR 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Dennis Allan Knee 2. SEX Male 3'1A•TE OF DEATH (Mo., Day, Yr.) January 3, 2016 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Carbon, Iowa 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) (Yrs.) 74 MOS. DAYS HOURS MINS. February 20, 1941 7. SOCIAL SECURITY NUMBER 482 -50 -5867 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Home ❑ DOA ❑ Other (Specify) 8b. FACILITY -NAME (If not Institution, give street and number) 2414 LaMar Avenue 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 i8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 2414 LaMar Avenue re. STREET AND NUMBER a APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Carolyn Louise McLaren 11. FATHER'S -NAME (First, Middle, Last, Suffix) Glen Knee 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Doris Porter 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Carolyn Louise Knee 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) January 6, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 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, APPROXIMATE INTERVAL 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: onset to death IMMEDIATE CAUSE (Final a) Coronary Artery Disease Chronic disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death Sequentially list conditions, if b) 1 1 any, leading to the cause listed 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: ; onset to death I Enter the UNDERLYING CAUSE c) 1 (disease or Injury that initiated ` the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST 1 d) 1 t 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Diabetes Mellitus 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 0 N 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 clays to 1 year before death ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ DriverlOperator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO • 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE A W F 6Z 23a. DATE OF DEATH (Mo., Day, Yr.) January 3, 2016 9 % z 2 3b. Ye (4 Y o c : w z 2 0 V ~ 0 o 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH DATE SIGNED (Mo., Day, Yr.) J anuary 4, 2016 23c. TIME OF DEATH 08:26 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD 8 4 0 1d. To the best of my knowledge, death occurred at the time, date and place 2 G and due to the cause(s) stated. (Signature nd Title) 2 Ryan D. Crouch, DO 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 Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) January 7, 2016 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND SERVICES, IT CERTIFIES THE 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 VIT41: -I &!ORQ$ DATE OF ISSUANCE 01/13/2016 LINCOLN, NEBRASKA 201803562. CERTIFICATE OF DEATH STANLEY S. GOC/'RER ASSISTANT STATE REGISTRAR' DEPARTMENT OF HEALTH AND HUMAN SERVICES.-- STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE' • ' • 16 00049