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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 if
<br />DATE OF ISSUANCE RUSSELL FOSLER
<br />5/15/2019
<br />201903083 ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />LINCOLN, NEBRASKA
<br />'urSuant 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 residedat the time of death.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Jim L Gross
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />May 8, 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 />Chicago, Illinois
<br />(Yrs.)
<br />67
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />October 2, 1951
<br />7. SOCIAL SECURITY NUMBER
<br />545-90-8538
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITi-NAME (If not institution, give street and number)
<br />Veterans Affairs Medical 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 />i 3311 W. US Hwy 2
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />®YES ❑ NO
<br />i0a. 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 />Candace Joleen Eqdorf
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />William Gilbert Gross
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Lorrayne Rice
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk,) Yes 06/22/1970-05/26/1972
<br />14a. INFORMANT -NAME
<br />Candace Joleen Gross
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<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 />May 10, 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 MAILING 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 />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 arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines H necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a)Acute On Chronic Respiratory Failure
<br />aisease or conuit.cn resuaing
<br />onset to death
<br />Years
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if . b)Chronic Obstructive Pulmonary Disease
<br />any, leading to the cause listed
<br />onset to death
<br />Decades
<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 />CHF, Atherosclerotic Heart Disease
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 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 ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Dnver/Operator
<br />Passenger
<br />0
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ® NO
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant yothin the past year
<br />Suicide Could not be determined
<br />0 0
<br />0 Pedestrian
<br />❑ 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 8 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 />May 8, 2019
<br />To be completed by
<br />CORONERS PHYSICIAN
<br />of COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />May 10, 2019
<br />23c. TIME OF DEATH
<br />12:39 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />r 3d. 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 />Shawn S. Lawrence, MD
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the causes) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES 0 NO 0 PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Shawn S. Lawrence, MD, 2201 N Broadwell Ave.,
<br />26a. HAS ORGAN OR ISSUE s • ATION BEEN CONSIDERED?
<br />❑ YES i7 NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />Grand Island, , 68803
<br />!28a.REGISTRARSSIGNATURE___,
<br />28b.DATEFILEDBY REGISTRAR 4Mo., Day, Yr.)� May 13, 2019
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