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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 6/20/2019 LINCOLN, NEBRASKA 201903953 RUSSELL FOSLER ASSISTANT STATE REGISTRAR DEPARTMENT OF IEAI.1'HI 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. I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) John Brent Lippe 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) June 15, 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 (Mo., Day, Yr.) Sterling, Nebraska (Yra.) 71 MOS. DAYS HOURS MINS, Au• ust 6 1947 7. SOCIAL SECURITY NUMBER 506-68-1319 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ab. FACILITY -NAME (If not Institution, give street and number) 305 Brady Rd 0 ER/Outpatient ® Decedent's Home 0 DOA 0 Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) St. Libory 68872 ed. COUNTY OF DEATH Howard 9e. RESIDENCE•STATE Nebraska 9b. COUNTY Howard 9C. CITY OR TOWN St. Libory 9d. STREET AND NUMBER 305 Brady Rd 9e. APT. NO. 9f. ZIP CODE 68872 9g. INSIDE CITY LIMITS 0 YES ® NO 10a. MARITAL STATUS AT TIME OF DEATH El Married 0 Never Married ❑ Married, but separated" 0 Widowed ❑ Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Peggy Ann Seely 11. FATHER'S -NAME (First, Middle, Last, Suffix) Paul Lipps 12, MOTHER'S -NAME (First, Middle, Maiden Surname) Ida Ewers 13. EVER IN U.S. ARMED FORCES? Give (Ye, No, or unk.) Yes < 11/21/ dates of service If Yes. 967-06/25/1969 14a. INFORMANT -NAME Peggy Ann Lipps 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑Donation 16a. EMBALMER -SIGNATURE Stacie L Ruiz 16b. LICENSE NO. 1495 16c. DATE (Mo., Day, Yr.) June 24, 2019 ❑ Cremation 0 Entombment ❑ Removal ` ❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Rosedale Cemetery Rosedale Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island, Nebraska 17b, Zip Code 68801 CAUSE OF DEATH (See instructions Qnd examples) 1i. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. 00 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 1 necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting onset to death < 1 Month kt Math) DUE TO, OR AS A CONSEQUENCE OF: Sequentially het conditions. if b)Metastatic Non -small Cell Lung Cancer any, leading to the cause hsted a. onset to death >5 Years on line DUE TO, OR AS A CONSEQUENCE OF; Enter the UNDERLYINO CAUSE C) Chronic Obstructive Pulmonary Disease (disease or injury that initiated.. onset to death > 5 Years the events resetting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d)Pulmonary Embolism onset to death > 6 Months 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. SVT 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑YES l(]NO 20. IF FEMALE: 0 Not pregnant within past year ❑APregnant al time of death 21a. MANNER OF DEATH E Natural ❑ Homicide investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES rid NO 0 Not pregnant, but pregnant within 42 days of death 0 Net pregnant, but pregnant 42 days to 1 year before death 0 Unknown 4 pregnant within the past year ccidentPending 0 0 0 Suicide ❑ Could not be determined 0 Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE QF 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 be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH June 15, 2019 (Mo., Day, Yr.) AINO A3NNOlLY ALNflOO ° NYpISAHd S.213NOR03 peed. »a4 of 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) June 17, 2019 23c. TIME OF DEATH 05:46 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. To the beat of my knowledge, death occurred at the time. date and place �- and due to the causels) stated. (Signature and Title) Jennifer L. Brown, MD 24c. On the basis of examination and/or investigation, i 1 my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 12 YES 0 NO 0 PROBABLY 0 UNKNOWN 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES R] NO 26b. WAS CONSENT GRANTED? Not Applicable If 28a is NO ❑ YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE/ ? --- 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) June 18, 2019 ,e' -+" °