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STATE OF NEBRASKA r Yt 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 6/27/2016 LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Larry Eugene Fry 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Council Bluffs, Iowa 7. SOCIAL SECURITY NUMBER 505 -60 -2705 8b. FACILITY -NAME (If not Institution, give street and number) CH1 Health Nebraska Heart 8c. CITY OR TOWN OF DEATH (Include Zip Code) Lincoln 68526 RESIDENCE - STATE Nebraska 9d. STREET AND NUMBER' 3515 Gregory Ave 9b. COUNTY Hall lea. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Harold Curtis Fry 13, EVER IN U.S. ARMED FORCES? (Yes, No, or Unk,) NO IS. METHOD OF DISPOSITION ❑ Burial ❑ Donation ❑ Cremation ❑. Entombment El Removal ❑ Other (Specify) IMMEDIATE CAUSE disease or condition resulting in death) Segiteirtially list corlditiohs, if any, leading to the'yause listed on iinea. Enter the UNDERLYING CAUSE f4isease of injury that initiated. the events resemng in death! 22a. DATE OF INJURY (Mo., Day, Yr.) 224.. INJURY AT:WORN: DYs DNQ 23a. DATE OF DEATH (Mo., Day, Yr.) Jtane 13, 2016 STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Give dates of service if Yes. 16a. EMBALMER - SIGNATURE Not Embalmed 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska PARTI Enter the chain of events- -diseases, injuries, or complications- that directly caused the death. DO NOT enter terminal events such as cardiac arrest, iratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines R necessary. IMMEDIATE CAUSE: a) Pulmonary Failure DUE TO, OR AS A CONSEQUENCE OF: b) Bypass Surgery DUE TO, OR AS A CONSEQUENCE OF: c) Coronary Artery Disease DUE TO, OR AS A CONSEQUENCE OF: d) O. IF FEMALE! ❑ Nol pregnant within past year 0 Pregnant at time of death ❑ Not pregnant,, but pregnant within 42 days of death ❑ Net pregnant, but pregnant 43 days to 1 year before death Q Unknowp if pcegnantwitbinthe past year 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 201804260 14a. INFORMANT -NAME Sondra Rave Fry 22f. LOCATION OF INJURY - STREET &NUMBER, APT.NO. CITY/rOWN b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH June 15, 2016 05:20 PM 3d. To the best of my knowledge, death occurred at the time, date and place o and due to the cause(s) stated, (Signature and Title) �. Sager S. Damle, MD 25.:,01:1 TOBACCO USE CONTRIBUTE TO THE DEATH? I 28a. REGISTRAR'S SIGNATURE 5a. AGE - Last Birthday (Yrs.) 67 5b, UNDER 1 YEAR MOS. 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR. TOWN Grand Island lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Sondra Rave Dill 1 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Esther Maxine Shea CAUSE OF DEATH (See instructions and examples) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21a. MANNER OF DEATH ® Natural Homicide ❑ Accident 0 Pending Investigation ❑ Suicide ❑ Could not be determined W 7 a � ? o V Us `o 0 24c. 26a. HAS ORGAN OR TISSUE DONATION B A YES ❑ NO .'0 PROBABLY ® UNKNOWN ®YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Sager S. Damle, MD, 7440 S 91st St, Lincoln, Nebraska, 68526 DAYS 9e. APT. NO. 2. SEX Male 16b. LICENSE NO. EN CONSIDERED? 5c. UNDER 1 DAY HOURS 2117. IF TRANSPORTATION INJURY 0 Driver /Operator 0 l Passenger 0 Pedestrian ❑ Other (SpecifY) MINS. 8d. COUNTY OF DEATH Lancaster 9f. ZIP CODE 68801 STATE ate OTHER ❑ Nursing HomelLTC ❑ Decedent's Home ❑ Other (Specify) 3. DATE OF DEATH (Mo., Day, Yr.) June 13, 2016 6. DATE OF BIRTH (Mo., Day, Yr.) March 22, 194'. ❑ Hospice Facility 1 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., y, Yr.) June 15,2016 onset to death 4.5 Weeks STATE Nebraska 17b. Zip Code 68801 APPROXIMATE INTERVAL onset to death 4 Weeks 4.5 Weeks 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? YES NO 21c. WAS AN AUTOPSY PERFORMED' ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSEOF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc.(Specify) P CODE 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH PRONOUNCED DEAD (Mo., Day, Yr. 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 Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO CI YES ® 110 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.). June 20, 2016