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ich may affect the estate cf the deceased are filed with the county court in the county where the decedent resided at the time of death. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Terry Patrick Gallagher 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) August 26, 2018 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Fort Smith, Arkansas 5a. AGE - Last Birthday (Yrs.) 76 513, UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (MO., Day, Yr.) March 6, 1942 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -54 -6273 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility 813. FACILITY -NAME (If not Institution, give street and number) 512 S. Berber ❑ ER/Outpatient El Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Cairo 68824 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE > Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Cairo 9d. STREET AND NUMBER 512 S. Berber 9e. APT. NO. 9f. ZIP CODE 19g. CITY LIMITS 68824 l EJ YES ❑ NO 10a. 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 Rita A Pease 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHERS-NAME (First, Middle, Maiden Surname) John Gallagher Velda Kemper 13. EVER IN U.S. ARMED FORCES? Give (Yes, No, or unk.) Yes < 08/07/ dates of service if Yes. 961 - 12/23/1964 14a. INFORMANT -NAME Rita A Gallagher 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑Burial ❑Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) August 27, 2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Aofel Funeral Home, 1123 W. 2nd, Grand Island. Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 1 8. PART f. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter teminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death Years respiratory arrest, or ventricular 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) cor pulmonale /Chronic Diastolic Congestive Heart Failure disease or condition resulting in death) onset death DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b)Severe COPD Years any, leading to the cause listed on line a• onset to death DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Tobacco Abuse Years (disease or injury that initiated - : the events remains is death( DUE TO OR AS A CONSEQUENCE OF: onset to death LAST d) , I. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Atrial Fibrillation, Diabetes Mellitus Type 2, Obesity 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES IKJ NO I. IF FEMALE: ❑ Not pregnant within past year ❑ P regnant at time of death 21a. MANNER OF D ® Natural ❑' Homicide ❑ Accident ❑ Pe Investigation Suicide Co determined ❑ 0 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 0 N ❑ Not pregnant, but pregnant within 42 days of death I ❑ Not pragnem, but. pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑! NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? _ ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE o section 31 npleted by, :ERYIPIER ILY 23a, DATE OF DEATH (Mo., Day, Yr.) August 26 2018 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) August 27, 2018 23c. TIME OF DEATH 09:20 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 12 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) Jay C. Anderson, MD 24e. On the basis of examination and/or investiga ion, in my opinion death occurred at the time, date and place and due to the cau e(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? El YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES El NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 REGISTRAR'S SIGNATURE 1 28a. 2'" C-"" "_ - - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) August 29, 2018 STATE OF NEBRASKA 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 9/5/2018 LINCOLN, NEBRASKA :vim " i9s a` RUSSELL FOSLER DEPARTMENT HEALTH AND INTERIM ASSISTANT STATE REGISTRAR HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH