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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 iA 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 9/12/2017 LINCOLN, NESRASKA ■•■•■■• 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Donald Lee Naab 4. CITY: AND STATE OR TE Comstock, Nebraska ITORY, OR FOREIGN COUNTRY OF BIRTH 7. SOCIAL SECURITY NUMBER 506 -40 -1879 $b, FACILITY -NAME (If not Institution, give street and number) CC 0 v r- York General Hearthstone uJ 8c. CITY OR TOWN OF DEATH (Include Zip Code) ix York 68467 J ' 'AS z 3 • d. STREET AND NUMBER" • 203E 19TH Street .0 biz 02 m 95, RESIDENCE -STATE Nebraska MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married Married, but Separated :€ ❑ Widowed ❑ Divorced ❑ Unknown 1. FATHER'S -NAME (First, Middle, Last, Suffix) Walter Ivan Naab • 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Urtk.) No 1 15. METHOD OF . DISPOSITION ❑ Burial ' ❑ Donation E Cremation ❑ Entombment ❑ Removal ,❑ Other (Specify) 5a. AGE! - Last Birthday (Yrs.) 82 9b. COUNTY Hall 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street, Grand Island. Nebraska 5b. UNDER 1 YEAR M OS, 16a. EMBALMER - SIGNATURE Not Embalmed DAYS 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) September 1, 2017 6. DATE OF BIRTH (Mo., Day, Yr,) August 11, 1935 Fe, PLACE_ OF DEATH HOSPITAL ❑ Inpatient ❑ !ER/Outpatient ❑ DOA OTHER ® Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) Hospice Facility 8d. COUNTY OF DEATH York 9c, CITY OR TOWN Grand Island' 9e. APT. NO. 9f. ZIP CODE 68801 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Carolyn Josephine Pope 1 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ferne Adelaide Donahue 14a. INFORMANT -NAME Carolyn Josephine Naab 16b. LICENSE NO. 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day , Yr.) September 4, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY 1 TOWN STATE Gibbon ..NeOraskai 17b. Zip` Code s. 68801 CAUSE OF DEATH (See instructions and examples) 18. PART 1. Enter tes chain of events diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, �!ty r•es± n< +s.:r¢ tr ,ran vr'!'hout shn r0 the etioirgy, pn tlOI' ARRRt - tnArc Frter only n e couse on .+ lino. Add additional lines d ne^.essanf IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final disease or condition resulting *death) • DUE TO, OR AS A CONSEQUENCE OF: Sequentially lust conditions, it b) a t _.. any, Wading Wading to the - tause bated on line a. Enter the UNDERLYING CAUSE (liseaye or in /ury initidted:: ;he events resulting in death) • LAST: 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not otoot ant,tud Pregnant 43 days to 1 year before death ❑ tlnknawn it pr'.egna with the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 2d. INJURY AT >WORK? ❑YES ❑NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 23a. DATE OF DEATH (Mo., Day, Yr.) Septertiber >1, 2017 23b, DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH September 1, 2017 08:00 AM 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Joseph C, Erwin, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES ❑ NO ❑ PROBABLY ® UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Joseph C. Erwin, MD, 2114 N. Lincoln Ave, Ste A, York, Nebraska, 68467 28a.: ::REGISTRARS SIGNATURE 0,62 r /1 'L � ' al Acute Bacterial Pneumonia DUE TO, OR AS A CONSEQUENCE OF: C) DUE TO, OR AS A CONSEQUENCE OF: d) 1 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED L r �' / likliMk,k fatelAt p ;?' • 201805381 STANLEY S. OOPER ASSISTANT S ATTE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) CITY/TOWN ,; °!wit'✓ 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian Other (Specify) STATE 24a. DATE SIGNED (Mo., Day, Yr.) c. PRONOUNCED DEAD (Mo., Day, Yr.) rik } �ak�"'iK h. -_�.` '7;"C%°�k* 7 eP�i•idrY „€3;tM`'�v. l APPROXIMATE INTERVAL :: onset to death Weeks onset to death onset to death onset ta' 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 50 NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 61 NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH ?. ❑ YES ❑ NO ZIP CODE 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 causes) stated. (Signature and Tide) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? ❑ YES 11 NO Not Applicable if 26a is NO DYES 0 NO 28b. DATE FILED BY REGISTRAR,: (Mo:, :Day, Yr.) September 6, 2017