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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 7
<br />DATE OF ISSUANCE
<br />3/7/2019
<br />LINCOLN, NEBRASKA
<br />RUSSELL SLER
<br />2O9U I ASSISTANT STATE REGISTRAR
<br />DEPARTMENT
<br />OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />19 02679
<br />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.
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Richard Otto Wood
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />February 26, 2019
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.}
<br />Central City, Nebraska
<br />(Yrs.)
<br />90
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />November 30, 1928
<br />7. SOCIAL SECURITY NUMBER
<br />505-36-8612
<br />8a. PLACE OF DEATH
<br />HOSPITAL Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME (drier
<br />632 Meves '
<br />Institution, give street and number)
<br />�- 0 ER/Outpatient E Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />8d. COUNTY OF DEATH
<br />Hall
<br />38. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />632 Meves
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married
<br />❑ Married, bet separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Darletta Davis
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Walter Wood
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Argyle Schulz
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />('res, NO, or unll.) Yes 09/04/1952-09/01/1954
<br />14a. INFORMANT -NAME f
<br />Rick Wood
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.}
<br />February 27, 2019
<br />Cremation 0 Entombment
<br />❑ Removal 0 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 MA LING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home. 1123 W. 2nd. 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 arreet, 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) Chronic Obstructive Pulmonary Disease
<br />disease or condition resulting
<br />onset to death
<br />Years
<br />n death} DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if :' b)
<br />any, leading to the cause listed
<br />onset to death
<br />_.
<br />on line 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 />LAST 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 />- Hypertension
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />E YES ❑ NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of deathEl
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />--
<br />❑ YES ENO
<br />0 Not pregnant, but pregnant within 42 days of death❑Pedestrian
<br />0 Not pregnant, but pregnant 43 days tot year before death
<br />0 Unknown if pregnant within the past year
<br />Suicide Could be determined
<br />0 Su0 noterm
<br />0 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 />TO: be completed by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />February 27, 2019
<br />24b. TIME OF DEATH
<br />Approx. 08:00 PM
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />February 26, 2019
<br />24d. TIME PRONOUNCED DEAD
<br />09:32 PM
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />thetime, date and place and due to the cause(s) stated. (Signature and Title)
<br />Sarah Hinrichs, Hall Deputy County Attorney
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY E UNKNOWN
<br />26a. HAS ORGAN OR ISSUE • • AT1ON BEEN CONSIDERED?
<br />❑ YES i77 N3
<br />26b. WAS CONSENT GRANTED/
<br />Not Applicable if 26a is NO ❑ YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Sarah Hinrichs, Hall Deputy County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATUREtyY'?
<br />,pie✓" �� "
<br />28b. DATE FILED BY REGISTRAR (Mo.,Day, Yr.)
<br />March 4, 2019
<br />
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