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WHEN THIS 'r` 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 ,,1 • I
<br />2 019 0 4 2 9 3
<br />ASSISTANT STATED RESLER GISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DATE OF ISSUANCE
<br />4/18/2019
<br />LINCOLN, NEBRASKA
<br />1904714
<br />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.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />John Raymond Neville
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 10, 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 />York, Nebraska
<br />(Yrs.)
<br />94
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />June 4, 1924
<br />7. SOCIAL SECURITY NUMBER
<br />507-24-2975
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER I Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Central Nebraska Veterans Home
<br />0 ER/Outpatient ❑ Decedent's Home
<br />0 DOA ❑ Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Kearney
<br />Rd. COUNTY OF DEATH
<br />Buffalo
<br />_68847
<br />ga. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Buffalo
<br />9c. CITY OR TOWN
<br />Kearney
<br />9d. STREET AND NUMBER
<br />4510 East 56th Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68847
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />❑ Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Barbara J Kaliff
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Frank Patrick Neville
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Mary Beide
<br />13: EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(YES, No, or Unk.) Yes 05/18/1946-10/17/1947
<br />14a. INFORMANT -NAME
<br />Patti VanPelt
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15. METHOD -OF DISPOSITION
<br />® Burial ❑ Donation
<br />16a. EMBALMER -SIGNATURE
<br />Mark McBride
<br />16b. LICENSE NO.
<br />1199
<br />16c. DATE (Mo., Day, Yr.)
<br />April 15, 2019
<br />0 Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Aofel Funeral Home. 1123 W. 2nd. 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 4 necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a)Advanced Alzheimers
<br />disease or condition resulting
<br />onset to death
<br />5 Years Plus
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequemully list conditions, if -. sb)
<br />any, leading to the cause listed':
<br />_.n.-_"= t- 'i.nth
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or Nary 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 />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE: i
<br />0 Not pregnant within past year
<br />0APregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ENO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />ccidentPending
<br />0 0
<br />0 Suicide ❑ Could not be determined
<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 />Q YES Q NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET .9 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 />April 10, 2019
<br />To be completed by
<br />CORONER'S PHYSICIAN:
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Aaril 11 2019
<br />23c. TIME OF DEATH
<br />09:40 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.
<br />24d. TIME PRONOUNCED DEAD
<br />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 />Brad Rodgers, 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 cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY ® UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES E 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 />Brad Rodgers, MO, 2510 11th Ave, Kearney, Nebraska,
<br />68845
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Vr.)
<br />April 15, 201901
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