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STATE OF NEBRASKA
<br />WHEN THIS ; COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS je
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DATE OF ISSUANCE
<br />10/29/2018
<br />20190069
<br />LINCOLN, NEBRASKA
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased an filed with the county court in the county where the decedent resided at the time of death. 1
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Gaylord Leroy Jensen
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />October 18, 2018
<br />4. CITY AND STATE QR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5.9. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Seward, Nebraska
<br />(Yrs.)
<br />69
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />March 6, 1949
<br />7. SOCIAL SECURITY NUMBER
<br />506-66-7203
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />606 B Street
<br />0 ER/Outpatient 2 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWV OF DEATH lInclude Zip Corral
<br />St. Libory 68872
<br />8:1. C':'JNT( OF nEATH
<br />Howard •
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Howard
<br />9c. CITY OR TOWN
<br />St. Libory
<br />9d. STREET AND NUMBER
<br />606 B Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68872
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT J1ME OF DEATH ® Married 0 Never Married
<br />❑;Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Carol Jean Staab
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Jens Jensen
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Pearl Boesen
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Una.) ND
<br />14a. INFORMANT -NAME
<br />Carol Jean Jensen
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OFDISPOSITION16a.
<br />❑ Burial 0 Donation
<br />EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />October 21, 2018
<br />® Cremation ❑Entombment
<br />❑ Removal '❑ Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island, Nebraska
<br />17b, Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />VS. 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,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Sudden Cardiac Death
<br />- 33t:r '.on.,l:iotr;espcloy
<br />onset to death
<br />Minutes
<br />in death) onset to death
<br />DUE TO, OR AS A CONSE4UciJt:c v.==:
<br />Sequentially fist conditions, it b) Prostate Cancer
<br />'a yej,nt� in 11* co nes i'3te6
<br />air i
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) Hypertension
<br />(disease or injury that initiated
<br />onset to death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d) Diabetic Neuropathy
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />Type II Diabetes
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES 0 NO
<br />20. IF FEMALE: :
<br />0 Not pregnant within past year
<br />❑ Pregnant at time of death
<br />a
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />Accident Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />Passenger
<br />❑ g
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />❑ ;Not pregnant, but pregnant within 42 days of death❑Pedestrian
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />❑ ❑
<br />Suicide Could not be determined
<br />0 ❑
<br />❑ Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />T� he completed by
<br />MEI' •CAL CERTIFIER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)24a.
<br />g 2
<br />DATE SIGNED (Mo., Day, Yr.)
<br />October 19, 2018
<br />24b. TIME OF DEATH
<br />Approx. 10:00 PM
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />4_' y
<br />I , a Z
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />October 18, 2018
<br />24d. TIME PRONOUNCED DEAD
<br />10:15 PM
<br />123d. To the best
<br />of my knowledge, death occurred at the time, date and place
<br />o N O
<br />z z
<br />t- r6 p
<br />8 8
<br />24e, On the basis of examination.,-d;or ion, ie, it :ix opinion death ..crowed et
<br />me time, nate and place and due to' .rte causer') stated. (Signature and Title)
<br />David T. Schroeder, Howard County Attorney
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ❑ NO 0 PROBABLY ® UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />David T. Schroeder, Howard County Attorney, 612
<br />Indian St., Ste 3, St. Paul, Nebraska, 68873
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />October 22, 2018
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