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I l jl�ti;�i(i Stitie STATE OF NEBRASKA 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 7/24/2018 LINCOLN, NEBRASKA 201901023 RUSSELL FOSLER INTERIM ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 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) Neal Evan Kelley 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) July 4, 2018 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 6b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) O'Neill, Nebraska (Yrs.) 77 MOS. DAYS HOURS MINS. October 3, 1940 7. SOCIAL SECURITY NUMBER 508-50-6008 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility $b. FACILITY -NAME (If not Institution, give street and number) 2106 Circle Drive 0 ER/Outpatient ®Decedent's Home 0 Doi) ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska '> 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2106 Circle Drive 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS nX YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married ❑ Married, but separated', 0 Widowed 0 Divorced 0 Unknown -10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Dianne Miller 11. FATHER'S -NAME (First, Middle, Last, Suffix) James Kelley 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Marjorie Parks 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes iI09/23/1960-02/01/1963 14a. INFORMANT -NAME Dianne Kelley 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial 0 Donation 16a. EMBALMER -SIGNATURE Katie M. Smydra 16b. LICENSE NO. 1454 • 16c. DATE (Mo., Day, Yr.) July 8, 2018 ❑ Cremation 0 Entombment ❑ Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Inman Cemetery Inman 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. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) ie. 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) Multi -Vessel Coronary Artery Disease disease or condition resulting onset to death 24 Years in death( DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if :: b) any, leading to the cause listed >" line onset to death on a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE C) (disease or injury 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 in the underlying cause given in PART I. Diabetes Mellitus Type 2; Sleep Apnea; Carotid Artery Stenosis; Dyslipiderma Diastolic Dysfunction 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE: 0 Not pregnant within past year ❑ Pregnant at time of death 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY 0 [river/Operator 0Passenger 21c. WAS AN AUTOPSY' PERFORMED? ❑ YES ®NO 0 Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown if pregnant wit /f the past year Suicide 0 Could not be determined ❑ 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? : OYES ONO 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.) To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY.. ONLY 24a. DATE SIGNED (Mo., Day, Yr.) July 18, 2018 24b. TIME OF DEATH Approx. 11:00 AM 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) July 4, 2018 24d. TIME PRONOUNCED DEAD 11:44 AM _ 23d. To the best of my knowledge, death occurred at the time, date and place end due to the cause(s) stated. (Signature and Title) 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) S. Alex West, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES 0 NO 0 PROBABLY ® UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? DYES Lil NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print S. Alex West, Hall. Deputy County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801 28a. REGISTRAR'S SIGNATURE�,. 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) July 19, 2018 � � `""'�.