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A' Y'O 0 2didolitAtb. i STATE OF NEBRASKA Tiff 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 12/5/2017 LINCOLN, NEBRASKA 201805593 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH ate STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Larry Gene Brannagan 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Hastings, Nebraska 5a. AGE • Last Birthday (Yrs.) 76 6b. UNDER 1 YEAR MOS. DAYS 2. SEX Male 5c. UNDER 1 DAY HOURS 1 MINS. IMMEDIATE CAUSE (Final disease or condition resulting CAUSE OF DEATH See ns and exam • les g. PART I. Erderthe ;chain of events -- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respnatory arrest, or ventriejllar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a tine.' Add additional lines if necessary. IMMEDIATE CAUSE: a) Reoccurrence Non- Hodgkin's Lymphoma, Complicated By High Grade Colonic Obstruction, recurrent Disease APPROXIMATEiINTERV onset to death 72 Hours 7. SOCIAL SECURITY NUMBER 505 -52 -5644 8b. FACILITY -NAME (If not Institution, give street and number) O CHI Health St. Francis 8a. PLACE OF DEATH HOSPITAL El Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Hall i ct i 8c. CITY OR TOWN OF DEATH (Include Zip Code) n Grand island 68803 AL Oa. RESIDENCE -STATE w Nebraska !. L ' 9d STREET AND NUMBER ;; 3211 Hiawatha Place 9b. COUNTY 9c. CITY OR TOWN Hall Grand Island 9e. APT. NO. I 9f. ZIP CODE i 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO b Oa. 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. Rose Mary Moody 11. FATHER'S -NAME (First, Middle, Last, Suffix) m Arvene G Brannagan r 12. MOTHER'S -NAME (First, Middle, Maiden Surname) J Theresa Phillips e 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME w (Yes, No, or Unk.) No Rose Mary Brannagan E 15. METHOD OF DISPOSITION E Burial ❑ Ornation ❑ Cremation ❑ Entombment ❑Removal 0 Other (Specify) 16a. EMBALMER-SIGNATURE Gwen K. Hvronemus 16d. CEMETERY, CREMATORY OR OTHER LOCATION Grand Island City Cemetery 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) ADfel Funeral Home. 1123 W, 2nd, Grand Island. Nebraska 17b, Zip rCode 68801 irl! death) Set ally )fst dead tiens, if any, feedinodo the cause listed on line a DUE TO, OR AS A CONSEQUENCE OF: b) Enter the UNDERLYING CAUSE {fliseaiie or injury bet mhiated::, DUE TO, OR AS A CONSEQUENCE OF: c) onset to death the events resultitI In dedtli) LAST s! DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. History Of Deep Venous Thrombosis, Pulmonary Embolism G% CO. IF FEMALE: ❑ NOt pregnant within pant year ILL; ❑ Pregnant at time of death ❑ Net pregnant,: but pregnant. within 42 days of death ❑ Not pregnant, pm !regnant. e3 days to 1 year before death ❑ Unknown if pregnant w thin the past year E 22a. DATE OF INJURY (Mo., Day, Yr.) • O u 22d. INJ URY AT WORI(? ❑ YES } N0 22b. TIME OF INJURY 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 3a. DATE OF DEATH (Mo., Day, Yr.) Noverrtber 25, 2017 3b. DATE SIGNED (Mo., Day, Yr.) November29, 2017 23c. TIME OF DEATH 08:42 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) Jane A. McDonald, MD .... ...:.... ...... ...... Y 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES E NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jane A. McDona.ld., MD, 800 N Alpha Street, Grand Island, Nebraska, S 28a. REGISTRA R'S SIGNATURE / A 1" 16b. LICENSE NO. 1448 CITY / TOWN Grand Island 21b, IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE • • ATION BEEN CONSIDERED? ❑ YES El NO 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 3. DATE OF DEATH (Mo., Day, Yr ) November 25, 2017 6. DATE OF BIRTH (Mo., Day, Yr ) November 5, 1941 14b. RELATIONSHIP TO DEGEDFNT,. Spouse 16c. DATE (Mo., Day Yr.) November 28, 2017 STATE Nebraska 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES E NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E 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) 24o. 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 Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 1, 2017