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Pit#9 9r:3 pix 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 RUSSELL FOSLER 10/2912018" LINCOLN, NEBRASKA ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 201807626 Pursuant to section 30-2413, demands for notice which may affect the estate of the de:eased 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) Darrell Lynn Reimers 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) October 16, 2018 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) St. Paul, Nebraska (Yrs.) 49 MOS. DAYS HOURS MINS. January 1, 1969 7. SOCIAL SECURITY NUMBER 508-86-8943 8a. PLACE OF DEATH HOSPITAL Q Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility Bb. FACILITY -NAME (If not Institution, give street and number) Veterans Affairs Medical Center 0 ER/Outpatient ❑ Decedent's Home 0 DOA ❑ Other (Specify) Sc. CITY OR rOiiPN OF DEA i N (include Zip Code) Grand island 68803 ltd. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 404 West 15th Street 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married ❑ Married, but separated 0 Widowed ® Divorced 0 Unknown 10b. NAME OF SPOUSE (First, .Middle, Last, Suffix) If wife, give maiden name 11. FATHER'S -NAME (First, Middle, Last, Suffix) William Reimers 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Wanda Snell 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk,) Yes 08/03/1987-11/02/1991 14a. INFORMANT -NAME Wanda Reimers 14b. RELATIONSHIP TO DECEDENT Mother 15. METHOD OF DISPOSITION ® Burial 0 Donation 16a. EMBALMER -SIGNATURE William D. Greenway 16b. LICENSE NO. 0913 16c. DATE (Mo., Day, Yr.) October 20, 2018 ❑ Cremation 0 Entombment ❑ Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Rose Hill Cemetery Palmer Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Greenwav Funeral Home. 802 Temolin. Palmer. Nebraska 17b. Zip Code 68864 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the: chain of events- -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) Acute Respiratory Failure disease or condition resulting onset to death Minutes in deaths JR. n _ .. .. ., y ..__ E_UNCE OF: Sequent,aily list conditions, if b) Decompensated Liver Failure any, leading to ..o cause listed onset to death 6 Months on line a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Cirrhosis Due To Alcohol Dependence (disease or injury that initiated onset to death Years the events resulting'in death) DUE TO, OR AS A CONSEQUENCE OF: LAST 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. HTN, Esophagitis 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 10 NO 20. IF FEMALE: 0 Not pregnant within past year 0 Pregnant at time of death 21a. MANNER OF DEATH ® Natural 0 Homicide Accident Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO ❑ 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 Suicide ❑Could not be determined 0 Pedestrian ❑,Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.)122b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ONO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE oleete Tobe comp pled by MEDICAL CERTIFIER ONLY 23a, DATE OF DEATH (Mo., Day, Yr.) October 16, 2018 To be completed by CORONER'S PHYSICIAN or COUNTY AT'ORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) 1 23c. TIME OF DEATH October 19, 2013 1 05:50 PM 24c. PRONOUNCED DEAD (Mo,. Day, Yr.) 24d. TIME PRONOUNCED DEAD _ 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Shawn S. Lawrence, 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 ® NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Shawn S. Lawrence, MD, 2201 N Broadwell Ave., Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 19, 2018