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STATE OF NEBRASKA nsv 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 8/9/2018 RUSSELL FOSLER DEPARTMENT HEALTH AND LINCOLN, NEBRASKA INTERIM ASSISTANT STATE REGISTRAR HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE DEATH 9a; RESIDENCE -STATE Nebraska 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Hubert Gene Gustafson 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH brasica Y 7. SOCIAL SECURITY NUMBER to - 445 -32 -2377 O Pb, FACILITY -NAME Of not Institution, give street and number) • Tiffany Square Care Center ✓ 8c. CITY OR TOWN OF DEATH (Include Zip Code) is Grand Island 68803 C G 9d. STREET AND NUMBER .8 106 West 23rd Street cs 10a, MARITAL STATUS AT TIME OF DEATH El Married 0 Never Married 0 Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown tit 11. FATHER'S -NAME ( First, Middle, Last, Suffix) 3 Orville F Gustafson • 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No or Unit.) Yes 08/04/1955- 05/22/1957 8 15,. METHOD OF DISPOSITION L 12 Burial ' 0 Donation ❑ Cremation ❑ Entombment c ❑ >Removal ❑ Other (Specify) m t V t 20, IF,FEMALE: ❑ Not pregnant:within past year ❑ Pregnant at time of death ❑ N.ot pregnant; but Pregnant within 42 days of death ❑ Not pregnant, but pre days to 1 year before death ❑ Unkttowtt d Pregnant within the past year ,9 22a. DATE OF INJURY (Mo., Day, Yr.) UI 'D 22d. INJURY AT WORK? o ❑Yes ❑ NO i 28a. REGISTRAR SIGNATURE 16a. EMBALMER - SIGNATURE Chris McCoy 16d. CEMETERY, CREMATORY OR OTHER LOCATION Grand Island City Cemetery 22b. TIME OF INJURY ,p 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. ci O 52. AGE - Last Birthday (Yrs.) 83 >` 5b. UNDER 1 YEAR MOS. DAYS HOURS 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA OTHER ® Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 9b. COUNTY Hall 9c, CITY OR TOWN Grand! Island 9e. APT. NO. 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Rosalie Swedlund 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Pearletta I Elifritz 14a. INFORMANT -NAME Rosalie Gustafson 14b. RELATIONSHIP TO DECEDENT Spouse CITY / TOWN Grand Island 0 3 = 17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Aofel Funeral Home. 1123 W. 2nd, Grand Island. Nebraska 17b. Zip Code 68801 w CAUSE OF DEATH (See instructions and examples) 8. PART ), £nterthe chain ofevents- - diseases, injuries, or complications -that directly caused the death. DONUT enter tererinat events such as cardiac arrest, respiratory arrest or ventricular fibrillation without showing the etiology. DO NOT ABARE111ATE. Enter only one causelpn a line. Add additional lines if necessary. IMMEDIATE CAUSE: a) Parkinson's Disease IMMEDIATE CAUSE (Final disease or condition resulting onset to death Years APPROXIMATE INTERVAL w9' a: CS in death);.; .. ..... Sequentially list cendtdone, H any, leadiitg td tire - :cause listed on /ide DUE TO, OR AS A CONSEQUENCE OF: b) 'p m 5 Enter the UNDERLYING CAUSE 46, (disease or in)* that Initiated DUE TO, OR AS A CONSEQUENCE OF: c) onset to death 2 the events result stg in death) nN LAST DUE TO, OR AS A CONSEQUENCE OF: d) I 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Dysphagia co 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not he determined 21b. IF TRANSPORTATION INJURY Driver /Operator ❑ Passenger 0 Pedestrian 0 Other (Specify) 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 24a, DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH C 23a. DATE OF DEATH (Mo., Day, Yr.) Y 4 a Ig 1 : , 0 23b. DATE SIGNED (Mo„ Day, Yr 23c. TIME OF DEATH 41::t 240; PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD $ ° h z August 3, 2018 07:17 PM E co z C a O 23d. To the best of my knowledge, death occurred at the time, date and place z O 24e. On the basis of examination and /or investigation, in my opinion death occurred at o Travis S. and due to the cause(s) stated. (Signature and Title) 8 C the time, date and place and due to the cause(s) stated. (Signature and Title) Iii • r Hageman, MD o IL . 25. RID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR e a ATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? YES 12] NO 0 PROBABLY 0 UNKNOWN ❑YES 7 • Not Applicable if 26a is NO ❑YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print T ravis S. Hagerman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28b. DATE FILED BY REGISTRAR(MO., Day, Y r August 7, 2018 2. SEX Male 5c. UNDER 1 DAY MINS. 3. DATE OF DEATH (Mo., Day, Yr.) August 1, 2018 6. DATE OF BIRTH (Mo., Day, Yr.) July 14, 1935 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 16c. DATE (Mo., bay, Yr) August 6, 2018 STATE Nebraska 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? . ❑ YES::: .. NQ: 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ❑ NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSEOE' ❑ YES ❑ NO