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.' "a, >; V .lY''r, :Okada 4 i • i n'(!h ),. 'fl, '7,11p STATE OF NEBRASKA moinixakay 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Josef A Jackson 4, CITY! AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Milwau kee, Wisconsin 7. SOCIAL SECURITY NUMBER 506 -34- 8958 5a_ AGE - Last Birthday (Yrs.) 92 5b. UNDER 1 YEAR MOS. 8a. PLACE OF DEATH HOSPITAL Q( Inpatient DAYS 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) March 16, 2018 July 22, 1925 6. DATE OF BIRTH (Mo., Day, Yr.) OTHER ❑ Nursing Home /LTC ❑ Hospice Facility tY 0 ' Veterans Affairs Medical Center yec. CITY Or'. T;YVN OF DEA.T:; .,:+c):ide ZIP C:r'e) 0 I- 8b. FACILITY -NAME (If not Institution, give street and number) 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 919 Pleasant View Dr 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 Ix DATE OF ISSUANCE STANLEY COOPER 201 80587 ASSISTA STATE REGISTRAR 3/26/2018 DEPARTMENT HEALTH AND LINCOLN, NEBRASKA HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIF 'CAT E OF DEATH Grand Island 68803 a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated:: ❑ Widowed ❑ Divorced ❑ Unknown 11. F ATHER'S -NAME (First, Middle, Last, Suffix) Oscar A Jackson 13. EVER IN U.S ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 12/10/1943- 04/03/1946 15. METHOD OF DISPOSITION ® Burial ❑ Donation Stacie L. Ruiz ❑ Cremation ❑ Entombment 0 Removal Q Other (Specify) 7a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska 18. PART I. Enter the t:haln of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventribular 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)d; ongestive Heart Failure disease or condition resulting in death) SegUevtieiiy ll$t comfitc any, ieading to the cause or, line a. Enter the UNDERLYING CAUSE ^ ( disease: ar injury;(fia t indieteit O .. ._. .. _. _).. he . events resultttt_ deathh) LAST- 20. IF FEMALE: ❑ Not pregnant Within past year El Pregnant at time of death ❑ Not pregnant, but pregnant ❑ Not pregnant, but within 42 days of death pregnant 43 days to 1 year before death Unknown irpregnaet Within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. .INJURY ATWORK7 • p YES DNo 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 23a. DATE OF DEATH (Mo., Day, Yr.) March 16, 2018 Shawn S. Lawrence, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑NO PROBABLY ❑ UNKNOWN a. REGISTRAR'S SIGNATURE 9b. COUNTY Hall 16a. EMBALMER- SIGNATURE 14a. INFORMANT - NAME:. Vonna Jackson 16d. CEMETERY, CREMATORY OR OTHER LOCATION Sc. CITY OR TOWN Grand Island 9e. APT. NO. 10b. NAME OF SPOUSE (First, „ Middle, Last, Suffix) If wife, give maiden name Vonna ,Deane Rockwell 12. MOTHER'S - NAME (First, Middle, Maiden Surname) Inez Leurinda Bingham Arnold Cemetery Arnold DUE TO, OR AS A CONSEQUENCE OF: b)Atherosclerotic Heart Disease DUE TO, OR AS A CONSEQUENCE OF: C) 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. COPD, Hyperlipiderrtia Dementia 22e. DESCRIBE HOW INJURY OCCURRED 23b. DATE $I4N'ED (Mo., Day, Yr.) 23c. TIME OF DEATH Marr.h 21 201.,3 05 : 09 PM d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) CAUSE OF DEATH (See instructions and examples) 21a. MANNER OF DEATH ® Natural ❑ Homicide 0 Accident ❑ Pending Investigation ❑ Suicide 0 Could not be determined 22b. TIME OF INJURY 122c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) CITY /TOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Shawn S, Lawrence, MD, 223 South E St, Broken Bow, Nebraska, 68822 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES tin NO ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA -�- ❑ Cther (Specify) OCAI TY 3F DEATh 1615 LICENSE NO. 1495 Hall CITY / TOWN 21b. IF TRANSPORTATION INJURY Driver /Operator ❑ Passenger 0 Pedestrian 0 Other (Specify) STATE 24a. DATE SIGNED (Mo., Day, Yr.) 9f. ZIP CODE 68801 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24b. TIME OF DEATH 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) 9g. INSIDE CITY LIMITS [21 YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.).' March 23, 2018 STATE Nebraska 17b. Zip Cod 68801 APPROXIMATE "INTERVAL onset to death Years onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACT ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 24d. TIME PRONOUNCED DEAD 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑'YES ❑ NO 28b. DATE FILED BY REGISTRAk(Mo., Day, Yr.)' March 23, 2018 21d. WERE AUTOPSY FINDINGS AVAILABLE -: TO COMPLETE CAUSE OF DEA ?:. ❑ YES ❑ NO