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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 1/28/2019 LINCOLN, NEBRASKA 201900716 RUSSETA ASSISTANT STATEE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH' AND HUMAN SERVICES CERTIFICATE OF DEATH 19 00794 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) Thomas Joseph Corkle 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) January 17, 2019 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.) Norfolk, Nebraska (Yrs.) 76 MOS. DAYS HOURS MINS. August 24, 1942 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER 2 Nursing Home/LTC 0 Hospice Facility ::.508-56-1718 8b. FACILITY -NAME (If not Institution, give street and number) Tiffany Square Care Center 0 ER/Outpatient 0 Decedent's Home ❑ DOA 0 Other(Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2008 W. Koenig 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but Separated) 0 Widowed ❑ Divorced 0 Unknown 16b. NAME OF SPOUSE (First, '= Middle, Last, Suffix) If wife, give maiden name Anita J Deckert 11. FATHER'S -NAME (First, Middle, Last, Suffix) John F Corkle 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mabel Ann Daly 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or link.) No 14a. INFORMANT -NAME Anita Corkle 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial 0 Donation 16a. EMBALMER -SIGNATURE : Stacie L Ruiz 16b. LICENSE NO. 1495 16c. DATE (Mo., Day, Yr.) January 21, 2019 ❑ Cremation ❑Entombment ❑ Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island, Nebraska 17b. Zips Code 68801 CAUSE OF DEATH (See instructionsand examples) tS. PART 1. 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 ventri4ulsr 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) Cirrhosis disease or condition resulting onset to death Years in death} DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b)Nonalcoholic Fatty Liver Disease any, leading [tithe cause listed line onset to death Years on a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or in/Ory that initiated '. onset to death 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 Diabetes in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 2 NO 20. IF FEMALE: - 0 Not pregnant within past year ❑Pregnant at time of death me eat 21a. MANNER OF DEATH ® Natural ❑ Homicide EI Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator El 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO ❑ Not pregnant, but pregnant within 42 days of death ❑ NM pregnant, but pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year 0 Suicide 0 Could not be determined ❑ Pedestrian ET 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 LINO 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 23a, DATE OF DEATH (Mo., Day, Yr.) Jartuary l7, 2019 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) January 23, 2019 23c. TIME OF DEATH 07:01 AM 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) Travis S. Hausman, MD 24e. On the basis of examination and/or investigation, in my opinion death occurred at thetime, date and place and due to the cause(s) stated. (Signature and Title) 25. DID. TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES I NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR ISSUE I • ATION BEEN CONSIDERED? 0 YES 2 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 Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE A 28b. DATE FILED BY REGISTRAR (Mo. Day, Yr.) January 23, 2019