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<br />STATE OF NEBRASKA
<br />•
<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 />3/27/2017
<br />LINCOLN, NEBRASKA
<br />201903938
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />17 03
<br />809
<br />To be completed/verified by: FUNERAL DIRECTOR 1
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Bernard John Kimminau
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />March 18, 2017
<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 />Deweese, Nebraska
<br />(Yrs.)
<br />77
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />September 6, 1939
<br />7. SOCIAL SECURITY NUMBER
<br />508-44-7409
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER E Nursing Home/LTC 0 Hospice Facility
<br />Bb. FACILITY -NAME (If not Institution, give street and number)
<br />Good Samaritan Society -Wood River
<br />0 ER/Outpatient ❑ Decedent's Home
<br />0 DOA 0 Other(Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)Ed. COUNTY OF DEATH
<br />Wood River_ 68883 l Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Wood River
<br />9d. STREET AND NUMBER
<br />1211 Lilly Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married
<br />❑ Married, butseparated} 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Sharyl Baker
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Phillip Kimminau
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Erma Drapal
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 07/31/1958-12/23/1960
<br />14a. INFORMANT -NAME
<br />Sharvl Kimminau
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />0 Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />March 21, 2017
<br />®Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />ADfel Funeral Home, 1123 W. 2nd. Grand Island. Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />To be completed by: CERTIFIER
<br />11t. PART I. Enter the Chadic( 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 1 necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Non Small Cell Lung Cancer
<br />onset to death
<br />1 Year
<br />in death)
<br />Sequentially
<br />any, leading
<br /><, DUE TO, OR AS A CONSEQUENCE OF:
<br />lir, conditions, if 7.. b)
<br />to the Cause listed
<br />doath
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease of Mtury 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 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Diabetes
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES E 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 />E Natural 0 Homicide
<br />Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />: 0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ENO
<br />O Not pregnant but pregnant within 42 days of death
<br />0 Not pregnant, but pr¢gltant 43 days to 1 year before death
<br />0 Unknown it pregnant within the past year
<br />AccidentPending
<br />0 0
<br />0 0 Could not be determined
<br />❑SuicidePedestrian
<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 ❑ NO
<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 />23:.. OATS
<br />March
<br />CC OrATH r^ t., Pay. Yr.;
<br />18, 2017
<br />To be completed by
<br />CORONER'S PIIYSICIAN
<br />or COUNTY Al fORNEY
<br />ONLf
<br />24a DATE SIGNED (Mo., Day. Yr.)
<br />1 24b. TIME OF DEATH
<br />2313. G'::T
<br />March
<br />aE EV (Mo.. Dry. Yr.)
<br />21, 2017
<br />1 23c. TIME OF DEATH
<br />09:40 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr. M
<br />24d. TIME PRONOUNCED DEAD
<br />111
<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 />Gary Settje, MU
<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 cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES E NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BLEN CONSIDERED?
<br />❑ YES ENO CONSIDERED?
<br />26b. WAS CONSENT GRANTED?
<br />Applicable if 26a is NO DYES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Gary Settle, MD, 2116 W Faidley #400, Box 9802,
<br />Grand Island, Nebraska, 68803
<br />•
<br />28a, REGISTRAR'S SIGNATURE �I , (l"
<br />�/p
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) : I
<br />March 22, 2017
<br />
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