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<br />STATE OF NEBRASKA
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<br />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 r
<br />DATE OF ISSUANCE
<br />08/12/2019
<br />LINCOLN, NEBRASKA
<br />201904824
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA . DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />To Be CompietedNeriffad;by; FUNERAL DIRECTOR
<br />1. DECEDENTS -NAME (Met, Middle, Last, 3utlix)
<br />Michael Gordon Dimmitt
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo.DaY.Yr,t.:.
<br />March 17, 2012
<br />1. *NANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />8a. AGE -Last Birthday
<br />db. UNDER 1 YEAR
<br />88. UNDER 1 DAY
<br />4. DATE OF SUITII (Mo., Day,: Yt.)
<br />Grand Island, Nebraska
<br />(Yrs.)
<br />57
<br />MOS
<br />DAYS
<br />HOURS
<br />MWS.
<br />June 2, 1954
<br />7. SOCIAL SECURITY NUMBER
<br />505-78-9149
<br />8a. PLACE OF DEATH
<br />H TAL: ® bWatlent OTHER: 0 NWItng Home/LTC 0 Hoopla FaciWly
<br />8b. FACILITY -NAME (N not Institution, give strait and number)
<br />Veterans Affairs Medical Center
<br />0 ER/Outpatient 0 DeadenCs Hams
<br />❑DOA ❑Dd+er(sP. Y)
<br />le. CITY OR TOWN OF DEATH (include Zip Coda)
<br />Grand Island 68803
<br />ad. COUNTY OF DEATH
<br />Hall
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />8b. COUNTY
<br />Hall
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />84, STREET AND NUMBER
<br />1413 N. Wheeler
<br />Ss. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CRY LIMITS':
<br />III YM 0 No
<br />104. MARITAL STATUS AT TIME OF DEAN ®Monied 0 Naar Mwrled
<br />❑ Married, but .operated 0 Widowed 0 Divorced 0 Unknown
<br />106. NAME OF SPOUSE IFlrsl, Weddle, Last, Suflfx) M wife, Ow maid.. mama.
<br />Debra Allen
<br />11, FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Gordon Dimmitt
<br />12. MOTHER'S -NAME (Net, MIddte, Malden Surname)
<br />Glendora Murray
<br />13, EVER 110 U.& ARMED FORCES? Diva dates of sank* ifYes.
<br />(Yea, No, or Milt.) YeS 07/13/1971-09/18/1974
<br />14a. INFORMANT NAME
<br />Debra Dimmitt
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />19. METHOD AF DISPOSITION
<br />❑°u"" ❑D°""°"
<br />11la. EMBALMER-SSONATlRtE
<br />Not Embalmed
<br />1410. UCENSE NO.
<br />180. DATE (Mo., Day, Yr.)
<br />March 19, 2012
<br />®Creneaon ' ❑Baeareeneet
<br />©m..., 0an.tap. no
<br />ltd. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />Central Nebraska Cremation Gibbon Nebraska
<br />174. FUNERAL NOME NAME AND MNUNG ADDRESS (Street, City or Town, $tate)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska ;
<br />1710. Zlp Code
<br />68801
<br />[ W / To Be Competed by: CERTIFIER
<br />CAUSE OF DEATH (See instructions and examples)
<br />1t. PART I. f•e., Ito flMLyLByMa -Olson., Nates, or wmMiradoar• sat Meanly cannel Ifor d. th. DO NOT 0410leerwal .m10 much so 00141000.04, : APPROXIMATE INTERVAL
<br />0.p1 wory mew or writriculior Rabarion wswd anomie IM aaoroer. DO NOT ABBREVIATE. Rolm only one coma on m Mae. Add wirmar w woe 11 ..emery.
<br />IMMEDIATE CAUSE: : onset to death.
<br />1:l1EljIATE CAUSE (Fmal \/�'�' \ \} \ ` ' 1
<br />disease or condition resulting a) Q. 1 2 C Q A 1 Ar ` I
<br />In deem) QCC3i �c.5 ��Q 4C '.
<br />DU! T0, OR A3 A CONSEQUENCE OF:
<br />Saquentlaity list condition*, If b)
<br />any, loading to tin cause gated Q` `h 01 o 1 n •. , c 0 A,r c:l- IA t, cl\ tL 43'0r h Vt\ tA is, S\ tk EN t s
<br />onset to death
<br />on Bets a DUE T0, OR AS A CO =_ • 1'' E OF:
<br />Enter the UNDERLYING CAUSE dl
<br />infamy
<br />onset to death
<br />(disease or that Initiated
<br />1M nyenne rosuitiny In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />WT
<br />d)
<br />onset to death
<br />18. PART II, OTHER SIGNIFICANT CONOITIONS-Conditions contributing to the death but not resulting M tis
<br />A.�,� �i l `� 1.
<br />Qtt SbR•C O v i � 1tl1ckeAr \tC.Gee r itiv,VA;4'Z,
<br />t12e lY! �,
<br />undodying cause given In PART 1.
<br />ea(Cr�OblE+
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ S �N0
<br />211, IF FEMALE:.
<br />❑Not pregnant n within past year
<br />21a. RIVER OF DEATH r
<br />Naturae ❑ Homicide
<br />)
<br />2110. IF TRANSPORTATION INJURY
<br />0 DdvadOpen
<br />218. WAS AN AUTOPSY���...///PERFORMED?
<br />pD ltor ❑ YES O
<br />Tl
<br />❑Pregnant at the. of death
<br />❑Not pregnant, but pregnant within 42 days of death
<br />0101 pregnant, but pregnant 43 days to 1 year before Mind)
<br />0UnkaowrId pregnant within the past year
<br />Aeddenti] Pending Investigation
<br />0 SukWs 0 Could not be ds/srrrdnad
<br />0 Passenger
<br />0 Pedeatdan
<br />0 Otho. (Specify)
<br />21d.TO COMPLETE CAUSE WERE AUTOPSY aOF D
<br />DEATH?
<br />❑ YES
<br />22e.. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22e. PLACE OF INJURY -At home, fern, street, factory, office budding. construction alb, sec. (Specify)
<br />22d. INJURY AT WORK?
<br />0 YES JONO
<br />22.. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATDN OF INJURY - STREET L NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />$ M
<br />234. DATE OF DEATH (Mo., Day, Yr.)=
<br />ArDcAN V�'1aC
<br />$1W
<br />24a. DATE SIGNED (Ma Dar. Yr.)
<br />2410. TIME OF DEAN
<br />1,,
<br />II
<br />14g
<br />231)DATE SIGNED (Mo., Day, Yr.) 1230. TIME OF DEATH
<br />"••s. _ •_ _ !� �z am
<br />p[
<br />' } O r
<br />Sa. F
<br />tz,<�
<br />24c. PRONOUNCED DEAD (Mo.. Day, Yr.)
<br />24d. TWIE PRONOUNCED DEAD
<br />m
<br />B ypy��
<br />IO -g
<br />234. bast of 4.11191.111- death occurred at the Mme, date and place
<br />•n dw �� .. and Tide)
<br />/ 411 � ^
<br />u ur z
<br />2 g 8
<br />F E'Cf
<br />24e. On Sts basis of examination sndlor Investigation, In my opinton death occurred
<br />at tin dme, data and p140. and duo to the cauae(s) stated (Signature and Title)
<br />25, DO • - « - 1 S8 CO • "• : UTE TO THE 7
<br />El YES ®' c • 0 PROBABLY
<br />. HAS ORGAN OR TISSUEON BEEN CONSIDERED?
<br />❑ YEE r
<br />UN. WAS CONSENT GRANTED?
<br />B Not Applicable tele NO NO ❑ YES f te0
<br />29. NAME, /TILE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONE PHYSICIAN OR COUNTY ATTORNEY)
<br />R'3
<br />V\cir'' 1Qt11A\ew i e Ccl.fl. V C caaA N t madw311 f�atld'ss
<br />(Type or Prim)
<br />(Incl NFIkr A1tA_ te& K!) 3
<br />21a. REGISTRAR% SIGNATURE . r f
<br />I ,
<br />2810. DATE FILED 107 RE Si � ���� , Yr.)
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