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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
<br />DATE OF ISSUANCE
<br />9/20/2016
<br />LINCOLN, NEBRASKA
<br />201707390
<br />20190439K
<br />A.eve
<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 />To be completed/verified by: FUNERAL DIRECTOR l
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Richard Lee Geist Sr
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />September 12, 2016
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE • Last Birthday
<br />Bb. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Grand Island, Nebraska
<br />(Yrs.)
<br />86
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />June 7, 1930
<br />7. SOCIAL SECURITY NUMBER
<br />507-24-4668
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME Of not }nstitution, give street and number)
<br />2225 Viking Roat,i
<br />0 ER/Outpatient ® Decedent's Home
<br />0 DOA l7 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 />2225 Viking Road
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />1Oa. 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 />Barbara Richeal
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Jacob Geist
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Marie Adler
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit.) No
<br />14a. INFORMANT -NAME
<br />Richard Geist Jr
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCoy
<br />16b. LICENSE NO.
<br />1191
<br />16c. DATE (Mo., Day, Yr.)
<br />September 16, 2016
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 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 />Aofel 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 />14. 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 R necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Alzheimers Dementia
<br />disease or condition resulting
<br />onset to death
<br />> 1 Yr
<br />m destlii DUE TO, OR AS A CONSEQUENC' OF:
<br />Sequentially list cceditions, it 4 b)
<br />any. lending to the Cause listed
<br />onset to death --
<br />on linea.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Einer the UNDERLYING CAUSE c)
<br />(disease or injury that initiated:..
<br />onset to death
<br />the events raautnng m deem( <, 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 />Chronic obstructive pulmonary disease, Lung Mass (not Biopsied)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES 0 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 />AccidentPendin Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />Passenger
<br />❑ g
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ® NO
<br />❑ Not pregnant, but pregnant within 42 days of death❑Pedestrian
<br />© Not nant 43 days to 1 year before death
<br />nut pregnant y
<br />0 Unknown if pregnant Within the past year
<br />❑ 0 g
<br />0 Suicide Could not be determined
<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? i
<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 b., completes: by
<br />MEDICAL CERT6 IER
<br />ONLY
<br />2 3a. DATE OF DEATH (Mo., Day, Yr.)
<br />September `,12 2016
<br />2 W
<br />a g
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />Z3b. DATE SIGNED (Mo , Day, Yr.)
<br />September 15, 2016
<br />23c. TIME OF DEATH = k Y
<br />02:13 PM E N
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr. j(
<br />24d. TIME PRONOUNCED DEAD
<br />3d. To the best of my knowledge, death occurred at me time, date and place
<br />and dos to the cause(s) stated. (Signature and Title)
<br />I Jennifer King, MD I
<br />a z O
<br />F § 5
<br />O s
<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 causets) stated. (Signature anu , mel
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES 0 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 ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jennifer King, MD, 2011 W Clarice St, Doniphan,
<br />Nebraska, 68832
<br />•
<br />28a, REGISTRAR'S SIGNATURE S. .�v
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 16, 2016
<br />(A)
<br />CO
<br />CO
<br />
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