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"!tS att!! STATE OF NEBRASKA , SFow.:,sr4 Aw •obloot - Nth 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 11/4/2016 LINCOLN, NEBRASKA 201900422 Cyr STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH To be cornpletedlverified by: FUNERAL DIRECTOR 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Galen Duane Loomis 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) October 17, 2016 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.) Columbus, Nebraska (Yrs.) 67 MOS. DAYS HOURS MINS. May 15, 1949 7. SOCIAL SECURITY NUMBER 507-64-7927 8a. PLACE OF DEATH HOSPITAL © Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Bryan Medical Center East 0 ER/Outpatient ❑ Decedent's Home <.❑ DOA. 0 Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Lincoln 68506 8d. COUNTY OF DEATH Lancaster 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 4361 Manchester Road e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS EI YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® 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 Vicki Lee Hoshor 11. FATHERS -NAME (First, Middle, Last, Suffix) Galen Berdette Loomis 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ruth Mae Wohlgemuth 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Urk.) No 14a. INFORMANT -NAME Vicki Lee Loomis 14b. RELATIONSHIP TO DECEDENT:. Wife 15. METHOD OF4DISPOSITtON ® Burial 0 Donation 16a. EMBALMER -SIGNATURE Katie M. Smydra 16b. LICENSE NO. 1454 16c. DATE (Mo., Day, Yr.) October 25, 2016 ❑ Cremation 0 Entombment ❑ Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Bellwood Cemetery Bellwood 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) To be completed by: CERTIFIER io 18. PART I. Enter the chain of everts- diseases, injuries, or complications -that directly caused the death. DO NOT enter tenninal 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) Dissected Aortic Aneurysm disease or condition resulting onset to death 48 Hours m deatnl DUE TO, OR AS A CONSEQUENCE OF: Sequentially lest conations, if ','. b) any, leading to the cause listed • onset to death -_ on linea. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) {disease or injury that initiated =. onset to death the events tSsuitng, LAST m death) DUE TO, OR AS A CONSEQUENCE OF: 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. Hypertension < 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE: 0 Not pregnant within past year ❑Pregnantt time of death 21a. MANNER OF DEATH ® Natural ❑ Homicide 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, taut pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year ❑Accident 0Pending Investigation ❑ Suicide ❑ Could not be determined 0 Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 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 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE be completed by MI DUCAL CERTIFIER -. ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) October 17, 2016 ---.- lo be completed by COI ONER'S PHYSICIAN of ;OUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) October 24, 2016 23c. TIME OF DEATH 06:41 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 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) Rya n D. Crouch, DO 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 j 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 Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803 (128a. REGISTRAR'S SIGNATURE 28b. DAT October 25, 2016 o., Day, Yr.I