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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 if
<br />DATE OF ISSUANCE 201904824
<br />5/24/2019
<br />LINCOLN, NEBRASKA
<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 />CERTIFICATE OF DEATH
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased al a 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 />Glendora May Dimmitt
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />May 19, 2019
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />I5a.
<br />(Yrs.)
<br />Neiigh, Nebraska 85
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />May 4, 1934
<br />7. SOCIAL SECURITY NUMBER
<br />506-36-8779
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />IBb. FACILITY -NAME (If not Institution, give street and number)
<br />II 419 N. Carey Ave
<br />0 ER/Outpatient ® Decedent's Home
<br />❑ cC.- J _
<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 />419 N. Carey Ave
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married ❑ 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 />Gordon Leo Dimmitt
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Glenn Earl Murray
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Sadie Helena Schober
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Kathy Lynn Dowtv
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />❑ curial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />May 21, 2019
<br />®Cremation 0 Entombment
<br />❑ Removal `❑ Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />15 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 A necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) End Stage Chronic Obstructive Pulmonary Disease
<br />onset to death
<br />10 Years
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if : ;. b)
<br />any, leading to tM cause listed`
<br />onset to death
<br />Ont line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that initiated
<br />onset to death
<br />the events resulting in deam) 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!.
<br />Malnutrition
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES ® 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 />0 Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ®NO
<br />© Not pregnant, Mut pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />0 Suicide 0 Could not be determined
<br />0 Pedestrian
<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 CF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK? 7
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />q. z
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />M3.,: 19, 201°
<br />z
<br />n,g z
<br />24a. DATE SIGNED (Mo., Day, Yr.) 124b. TIME OF DEATH
<br />3 F
<br />tj z
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />May 20, 2019
<br />23c. TIME OF DEATH
<br />01:35 PM
<br />1 1
<br />o » a
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME FRONOUNCED DEAD
<br />0
<br />2 c
<br />sr 8.1
<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 />Gary Settle, MD
<br />26 2
<br />A Z A
<br />~ 0 o
<br />24e. On Inc 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 anti Title)
<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 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Gary Settje, MD, 2116 W Faidley #400, Box 9802,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE��?
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 20, 2019
<br />u1
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