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/��1 1rs „r i tlx? 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 6/18/2018 LINCOLN, NEBRASKA 110,1A 41111, >rxt:11 201804058 STATE OF NEBRASKA - DEPARTMENT OF HUMAN SERVICES CERTIFI OF DEATH 1. DECEDENTS - NAME (First, Middle, Last, Suffix) Donald Franklin Moss 4. CITY! AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Cairo, Nebraska f. 7. SOCIAL SECURITY NUMBER co - 505 -56 -7777 m Sb. FACILITY -NAME (If not Institution, give street and number) CH1 Health St. Elizabeth d t-, R A d 5 • 9d. STREET AND NUMBER . 1410 Sheridan Place d 8c. CITY OR TOWN OF DEATH (Include Zip Code) Lincoln 68510 9a. RESIDENCE.STATE Nebraska 13. EVER IN U. ARMED FORCES? (Yes, No, or Link.) NO 15. METHOD OP DISPOSITION 2 Burial 0 Donation ❑ Cremation ❑ Entombment ❑ Removal ;❑ Ottler;;(Specify) 9b. COUNTY Hall Give dates of service if Yes. 16a. EMBALMER-SIGNATURE Stacie L. Ruiz 5a, AGE'-. Last Birthday (Yrs.) 60 14a. INFORMANT -NAME Donna Lee Moss 513. UNDER 1 YEAR MOS. 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 9c. CITY OR TOWN Grand Island 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (Firs Donna Lee Price Middle, Last, Suffix) If wife, give maiden name 11. FATHER'S -NAME (First, Middle, Henry Fred Moss Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Viola K Kruse DAYS 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 8d. COUNTY OF DEATH Lancaster 9f. ZIP CODE 68803 17a. 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.) April 28, 2018 6. DATE OF BIRTH (Mo., Day, Yr.) November 10, 1937 9g. NODE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) May 7, 2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Cemetery CITY /TOWN Grand Island STATE Nebraska 17b zip Code 68801 CAUSE OF DEATH (See instructions and examples) 1a. PART I. Enter the sham of events- - diseases, injuries, or complications -that directly caused the death. DO NWT enter terminal events such as cardiac arrest, respiratory arrest, nr 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) Spontaneous Bacterial Peritonitis disease or condition resulting onset to death Days APPROXIMATE INTERVAL in death) DUE TO, OR AS A CONSEQUENCE OF: seeuentiallylist conditions, If b) Metastatic Pancreatic Adenocarcinoma -' any, leading to the Cause fisted on line a DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease Or injury that initiated . onset to death DUE TO, OR AS A CONSEQUENCE OF: d) onsetaodeath 0) v ;xs 20.IF:FEMALE: ❑ Not pregnatt:within past year t? ❑ Pregnant at time of death .0 . ; ❑ Not ptegnant,but pregnant within 42 days of death ❑Not pregnant, but pregnant43 days to 1 year before death ❑ Unknown dpregnen: within the past year 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. . 22a. DATE OF INJURY (Mo., Day, Yr.) N 22d, INJURY AT WORK? ' OYES C3 NO ai v 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. O 23a. DATE OF DEATH (Mo., Day, Yr.) Aprit 28, 2018 23b DAtTE SIGNED (Mo., Day, Yr.) Mav1, 2018 22b. TIME OF INJURY 25. D(D TOBACCO •USE OONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 28a'REGISTRAR'S SIGNATURE 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation 0 Suicide ❑ Could not be determined 211,. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger 0 Pedestrian Other (Specify) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 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) 22e. DESCRIBE HOW INJURY OCCURRED CITY/TOWN STATE ZIP CODE 23c. TIME OF DEATH 11:59 PM 2 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) Jessica D. Taylor, MD .... ........ ....... ... 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES El NO 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 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 Tide) 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jessica D. Taylor, MD, 555 South 70th Street, Lincoln, Nebraska, 68510 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR May 4, 2018 STANLEY/. COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES