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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 10/5/2018 LINCOLN, NEBRASKA RUSSELL FOSLER INTERIM ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Pursuant to section 30-2413, demands for notice which may affect the estate of 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) Rilley John Nielsen 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) September 23, 2018 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday. Sb. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day,Yr,) Grand Island, Nebraska (Yrs.) 92 MOS. DAYS HOURS MINS. January 25, 1926. 7. SOCIAL SECURITY NUMBER 507-24-3465 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis ER/Outpatient 0 Decedent's Home 0 DOA ❑ Other (Specify) if.... C,,'. %JR iOhvii OF OEia iri tincivae Zip l.00e)8d. Grand Island 68803 COUNTY OF DEATH I Hall 9a. RESIDENCE -STATE Nebraska - 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 3027 W. Capital Ave 9e. APT. NO. 31 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES 0 NO 1Oa. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 0 Married, but separated ❑ Widowed ❑ Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Joanne. E Lassen 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname) John Nielsen Bertha Eggers 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or unk.) Yes 06/17/1944-08/03/1946 14a. INFORMANT -NAME Joanne E Nielsen 14b. RELATIONSHIP TO DECEDENT :. Spouse 15. METHOD OF DISPOSITION ® Burial 0 Donation 16a. EMBALMER -SIGNATURE Katie M. Smvdra 18b. LICENSE NO. 1454 16c. DATE (Mo., Day, Yr.) September 26, 2018 ❑ Cremation ❑Entombment 0 Removal ;❑ Other (Specify) 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) All Faiths Funeral Home. 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 1a. PART I. Enter the chain of everts- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL 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) Respiratory Failure onset to death 6 Days in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) Pneumonia any, leading to the cause lictedi' line onset to death 6 Days on a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury that initiated onset to death the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST'S d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Atrial Fibrillation 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE: : 9 Not pregnant within past year 9 Pregnant at time of dean❑ 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ®NO 0 Not pregnant, but pregnant within 42 days of death 0 Not pregnant; but pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year 0 SuicideCould not be` determined 0 9 Pedestrian ❑ Other(Specify) 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? ❑ YES 0 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 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY lis DATE Or DEATH min., Day, Y-.) September 23, 2018 To be completed by CORONER'S PHYSICIAN Or COUNTY ATTORNEY ONLY 24a. D t:712 S!OXED ;Mo., Day, Y 24.. ..:::E OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) Seetember 24 2018 23c. TIME OF DEATH 02:45 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD r 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) Isaac J. Berg, MD 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) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES l NO ❑ PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803 8a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 2, 2018