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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 LEG_ QEPO,�(T11R4F R VITAL RECORDS DATE OF ISSUANCE U l I� U l� 1 9/27/2016 LINCOLN, NEBRASKA STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH To be completed/verified by: FUNERAL DIRECTOR I 111 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Gerald Leigh Rapp Sr 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) September 10, 2016 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday Sb. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Holdrege, Nebraska (Yrs.) 78 MOS. DAYS HOURS MINS. July 30, 1938 7. SOCIAL SECURITY NUMBER 507-42-2746 8a. PLACE OF DEATH HOSPITAL © Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility Sb. FACILITY -NAME (If not Institution, give street and number) CHI He?I`h St. Francis ❑ ER/Outpatient ❑ Decedent's Home 0 DOA 0 Other (Specify) - Sc. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 802 E 15th Street 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES ❑ KO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 0 Married, but separated; 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Joan Elson 11. FATHER'S -NAME (First, Middle, Last, Suffix) Warren Rapp 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Blanche Reagan ,. 13. EVER IN U.S. ARME,D;FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Joan Rapp 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑Burial 0 Donation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) September 16, 2016 ® Cremation 0 Entombment ❑ Removal 0 Other (Specify) 16d CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Memorial Park Crematory Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston -Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska 17b. Zip Code 68803 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER SLI. PART I. Enter the chain df events --diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or vemtrictltar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Multiple Myeloma disease or condition resulting onset to death Months onset to death mdeatn) DUE TO, OR AS A CONSEQUENCE OF: _ ° .... v � Raiia; Fad,„ udyb any, leading to the cal.se listed on line a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury that initiated? onset to death the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES I I NO 20. IF FEMALE: ❑ Not pregnant within past year 0 Pregnant at time of death❑ 21a. MANNER OF DEATH ® Natural 0 Homicide Investigation 21b. IF TRANSPORTATION INJURY 0 DrIver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ®NO ❑ Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death Unknown if pregnant within the past year Accident ❑ Pending ❑ Suicide 0Could not be determined 0 Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF 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) 222d. 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 comp ated by.: MEDICAL CEitTIFIER ONL'f 23a. DATE OF DEATH (Mo., Day, Yr.)z September 10, 2016 r >5 z c U 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 231,. DATE SIGNED (Mo., Day, Yr.) I 23c. TIME OF DEATH September 12, 2016 I 12:20 AM K m : 0 y 24c. PRONOUNCED DEAD (Mo.. Day, Yr. l 24d. TIME PRONOUNCED DEAD 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Susan M. Newman, MD w c 0 p ~ O o 24e. On the basis of examination and/or investigation, in 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? 0 YES (0 NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?I 26b. WAS CONSENT GRANTED? ❑ YES ® NO I Not Applicable if 26a is NO 0 YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Susan M. Newman, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE �- C7C11,�� .iVi7�� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) September 21, 2016