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,r:-. sn ^,Xtrt 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 1124/2019 LINCOLN, NEBRASKA 201901720 RUSSELL FOSLER 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. f 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Gerald Wilbur Spencer 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) January 12, 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 (Md., Day, W.) Wolbach, Nebraska IYrs.) 92 MOS. !'DAYS HOURS I MINS. lune 16, 1926 7. 3OCIAL SECURITY NUMBER 506-22-6597 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Good Samaritan Society -Wood River 0 ER/Outpatient 0 Decedent's Home 0 DOA 0 Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Wood River 68883 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER `' 1532 Johnstown Rd. 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH 0 Married ❑ Never Married ❑ Married, but separated, ❑ Widowed 0 Divorced ® Unknown ^10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ray W Spencer Gertrude L Nitzel 13. EVER IN U.S, ARMED FORCES? Give dates of service if Yes. (Yes, No, or (ink.) Yes -- 10/24/1944-09/21/1946 14a. INFORMANT -NAME Barbara Rhoad 14b. RELATIONSHIP TO DECEDENT Niece 15. METHOD OF DISPOSITION ® Burial 0 Donation 16a. EMBALMER -SIGNATURE Matthew T. Myers 16b. LICENSE NO. 1411 16c. DATE (Mo., Day, Yr.) January 16, 2019 ❑ Cremation 0 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) Livinaston-Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska 17h.Zip Code 68803 CAUSE OF DEATH (See instructions and examples) til. 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) Senile Degeneration Of The Brain onset to death Yrs in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially fist conditions, if :'. b) any, leading to the cause listed on line a. onset to death DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or intury:that initiatnit;. onset to death the events resuktnpin death( ' DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Chronic Obstructive Pulmonary Disease, 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF:FEMALE: 'r 0 Not pregnant within past year 0 Pregnant at time of deathPassenger 21a. MANNER OF DEATH ® Natural ❑ Homicide - 0 Accident ❑ Pending Investigation 24b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 21c. WAS AN AUTOPSY PERFORMED?-:' ❑ YES ® NO 0 Not pregnant,but pregnant within 42 days of death.❑ 0 Not pregnant. Out pregnant 43 days to 1 year before death ❑Unknown it pregnant within the past year 0 Suicide 0 Could not be determned 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? ❑YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To bl completed by -;:...MEDICAL CERTIFIER:.. ONLY - _ 23a. DATE OF DEATH (Mo., Day, Yr.) January 12;12019 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) m 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) January 14, 2019 23c. TIME OF DEATH 09:31 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 1_ a23d. To the best of my knowledge, death ocnurred at the t tre. dote and.olacn and due to the ,.ause(s) stateo. (Signature and Title) Chad' Vieth, MD - .4.:. Cr. he gess v. e.u,unauon:.nmor mvxa.,ganmy io my opinion ceam occurred at the time, date and place and due to the causes) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES 0 NO 0 PROBABLY ® UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES El NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 1, 28a. REGISTRAR'S SIGNATUREy 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I January 18, 2019 '"�"