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STATE OF NEBRASKA 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 LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 1/28/2019 LINCOLN, NEBRASKA RUSSELL FOSLER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 201904986 19 00875 Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased Ere filed with the county court in the county where the decedent resided at the time of, death. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Donald Dean Hugh 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) January 13, 2019 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) ;. Alliance, Nebraska (Yrs.) 81 MOS. DAYS HOURS MINS. May 21, 1937 7. SOCIAL SECURITY NUMBER 506-42-4796 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 86. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis ❑ ER/Outpatient El Decedent's Home 0 DOA ❑ Other (Specify) 8c. 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 4224 Michigan Avenue 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married 0 Married, but separated El Widowed ❑ Divorced 0 Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Diane Lee Fritz 11. FATHER'S -NAME (First, Middle, Last, Suffix) Myron Pugh 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mamie McGinnis 13, EVER IN U.S.' ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 12/01/1960-11/30/1962 14a. INFORMANT -NAME Diane Lee Hugh 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑Donation 16a. EMBALMER -SIGNATURE Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) January 17, 2019 ❑ Cremation ❑Entombment [] Removal '❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 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, ' APPROXIMATE INTERVAL '< respiratory; arrest, or ventricular 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) Chronic Lung Disease disease or ccndnlon resulting onset to death 4 Weeks in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) any, leading to the cause Hated on line a. onset to death 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 ®NO 20. IF FEMALE: ❑ Not pregnant within past year ❑Pregnant at time of death 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? El YES ® NO ❑ Not pregnam, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days tot year before death 0 Unknown if pregnant within the past year ❑ Suicide ❑Could not be determined ❑ Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 1 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. 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 completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) January 13, 2019 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) January 22, 2019 23c. TIME OF DEATH 10:30 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 230. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) John A. Wagoner, MD 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? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print John A. Wagoner, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) January 24, 2019