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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 1/18/2019 LINCOLN, NEBRASKA 201900923 RUSSELL FOSLER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Pursumt to section 30.2413, demands for notice which may affect the estate of the deceased ate filed with the county court in the county where the decedent resided at the time of death. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Harvey K Reyner 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) January 6, 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.) Grand Island, Nebraska (Yrs.) - 88 MOS. DAYS HOURS MINS. March 31, 1930 7. SOCIAL SECURITY NUMBER 507-32-8483 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER E Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) TiffanyCr^ c Care C.pn«er 3u8r.. 0 ER/Outpatient El Decedent's Home El DOA 0 Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Iia. COUNTY OF DEATH Grand island 68803 I Hall 9a. RESIDENCE -STATE Nebraska . 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1424 W. Koenig St. 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS El YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married 0 Never Married 0 Married, but separated E Widowed ❑ Divorced El Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name LaJean Pfluckhahn 11. FATHER'S -NAME (First, Middle, Last, Suffix) Harvey G Reyner 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Stella V Power 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 12/05/1951-11/04/1955 14a. INFORMANT -NAME Julie Reyner 14b. RELATIONSHIP TO DECEDENT:. Daughter 15. METHOD OF DISPOSITION ®Burial 0 Donation 16a. EMBALMER -SIGNATURE Patricia R. Curran 16b. LICENSE NO. 1092 16c. DATE (Mo., Day, Yr.) January 14, 2019 ❑ Cremation ❑Entombment ❑ Removal ❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Curran Funeral Chapel. 3005 S. Locust St., Grand Island. Nebraska `' 17b. Zip Code 68801 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) Respiratory Arrest - disease or condition resulting onset to death Hours in death) DUE TO, OR AS A CONSEQUENCE OF: Sscaan',ahvhst condition, if '. VI Aspiration Pr4ur mcnia any, leading to the cause listed _ ' onset to death Days onlinea DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Dysphagia (disease of injury that Initiated onset to death Weeks the eventaresuhlne m death) DUE TO, OR AS A CONSEQUENCE OF: LasT d) Generalized Weakness Debility Of Age onset to death Months 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Cardiovascular Disease 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES. ENO 20. IF FEMALE: ElNot pregnant within past year ❑Pregnant at time of death 21a. MANNER OF DEATH E Natural ❑ Homicide El El Investigation 21b. IF TRANSPORTATION INJUR ❑'Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO ❑ Not pregnant, but pregnant within 42 days of death 0 Not'pregnant,but pragnans 43 days to I year before death ❑ Unknown if pregnant within the past year Suicide 0 Could not be determined ❑ Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? El YES ❑ 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 Q NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE a w 23a. DATE OF DEATH (Mo., Day, Yr.)Z January b az 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 2 - o 23b. DATE SIGNED (Mo., Day, Yr.) January 10, 2019 23c. TIME OF DEATH 10:50 PM 2. ' 6 I N t 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD e ¢ 3d. To the best of my knowledge, death occurred at the time, date and place -.. - ,.c:. t-4yc 'sod::: ,XXIec 'V i' -' : n n•:•- TI "I Zachary W. Meyer, MD g w 2 3 - g s 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? El YES E NO El PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES E NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Zachary W. Meyer, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) January 15, 2019