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<br />STATE OF NEBRASKA
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<br />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
<br />DATE OF ISSUANCE
<br />5/29/2018
<br />LINCOLN, NEBRASKA
<br />201903063
<br />STANLEY COOPER
<br />ASSISTA STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />. � To be completedtverified by: FUNERAL DIRECTOR
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Gary Duane Martin
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />May 20, 2018
<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 />St. Edward, Nebraska
<br />(Yrs.)
<br />86
<br />MOS.
<br />` DAYS
<br />HOURS
<br />MINS.
<br />February 12, 1932
<br />7. SOCIAL SECURITY NUMBER
<br />506-38-1933
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER El Nursing Home/LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Tiffany Square Care Center
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1132 N. Howard Ave.
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />El YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑,Married, but separated 0 Widowed 0 Divorced 0 Unknown-.
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Jacqueline Carol Michael
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Lester Oliver Martin
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Gladys Irene Hill
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) No
<br />14a. INFORMANT -NAME
<br />Jacqueline Carol Martin
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />®'curial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L. Ruiz
<br />16b. LICENSE NO.
<br />1495
<br />16c. DATE (MO., Day, Yr.)
<br />May 23, 2018
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island, Nebraska
<br />17b, Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />\ y \ w o be completey: CERTIFIER
<br />16. 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,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, 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) Melanoma Of Face With Metastatic Disease
<br />disease or condition resulting
<br />onset to death
<br />2 Months
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditkms, if : b)
<br />any, (leading to the: Cause l(sted'
<br />linea.
<br />onset to death
<br />on
<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 event; resulting in death( - DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST s, 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 />Parkinson's Disease, Hypertension, Mixed Hyperlipidemia,
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES < ®NO`
<br />20. IF FEMALE:
<br />0 Not pregnant Within past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES El NO
<br />❑ Not pregnant, but pregnant within 42 days o1 death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown, if pregnant within the past year
<br />0 Suicide 0 Could not be determined
<br />0 Pedestrian
<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 />OYES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />._ completed
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<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
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<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.
<br />24d. TIME PRONOUNCED DEAD
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<br />24n. On the basis o! examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the causes) stated. (Signatureand Title(
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES lid NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES '® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Kimberly A. Mickels, MD, 729 North Custer Avenue,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE S - !
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 25, 2018
<br />
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