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STATE OF NEBRASKA
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<br />WHEN THIS 'r' 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 ite
<br />DATE OF ISSUANCE
<br />1/18/2019`
<br />LINCOLN, NEBRASKA
<br />20 1900701 ASSISTANT STATEOREGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Pursant to section 30-: 413, demands for notice which may affect the estate of the dect+ased are filed with the county court in the county where the decedent resided at the time of death.
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Allen Ray Garton
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 7, 2019
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a, AGE - Last Birthday
<br />Sb. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (MO., Day, Yr.)
<br />Bridgeport, Nebraska
<br />(Yrs.)
<br />78
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />March 20, 1940
<br />7. SOCIAL SECURITY NUMBER
<br />508-48-7790
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Veterans Affairs Medical Center
<br />0 ER/Outpatient ❑ Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include 2.ip Code). 8d. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Doniphan
<br />9d. STREET AND NUMBER -
<br />323 Stub
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68832
<br />9g. INSIDE CITY LIMITS
<br />0 YES E NO
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married
<br />❑'Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />_ 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Sheila Ann Spuhler
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />John Garton
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Martha McNabb
<br />13. EVER, IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or tfnk.) Yes 04/17/1959-05/09/1962
<br />14a. INFORMANT -NAME
<br />Sheila Ann Garton
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑'Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />16b. LICENSE NO.
<br />1454
<br />16c. DATE (Mo., Day, Yr.)
<br />January 14, 2019
<br />® Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />Westlawn Memorial Park Crematory Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING 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 />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,
<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) Metastatic Pancreatic Cancer
<br />disease or condition resulting
<br />onset to death
<br />Months
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, d b)
<br />any, iwdicg ;., the couae listed'
<br />line
<br />onset to death
<br />on a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that initiated
<br />onset to death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LASTr '...: d)
<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 />Diabetes Mellitus, CAD, AFIB
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®; NO
<br />20. IP FEMALE:
<br />0 Not pregnant within pant year
<br />Pregnant time of d
<br />❑ atme eath
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide -
<br />❑ Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />❑ Not pregnant, but pregnant within 42 days of deathPedestrian
<br />❑Trot pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown If pregnant within the past year
<br />SuicideCould not be determined
<br />❑ 0
<br />❑ Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES ❑ 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 />DYES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />a w
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 7, 2019
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<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
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<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 8, 2019
<br />23c. TIME OF DEATH
<br />04:21 PM
<br />_ 1
<br />E N z
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />o et 0 3d. To the best of my knowledge, death occurred at the time, date and place
<br />2 U ;h6 cci-^.ail) =MAO. (+Ie.a:ure:... Jt.ej '
<br />g Shawn S. Lawrence, MD
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<br />24e. On the basis of examination and/or investigation,^ yn death oScurter.
<br />the tiny., _Ye nnJ nlc-c c ..d Jae :o the .a:.se,3) s:a:ad. (S.gnaiure and
<br />q
<br />i"itial
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES E NO 0 PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES I E NO
<br />26b. WAS CONSENT GRANTED'
<br />Not Applicable if 26a is NO ❑
<br />YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Shawn S. Lawrence, MED, 2201 N Broadwell Ave.,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE �}
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) „ I
<br />January 14, 2019
<br />
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