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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 />9/19/2017
<br />LINCOLN, NEBRASKA
<br />201905195
<br />A ate
<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 />28a. REGISTRAR'S
<br />SIGNATURE
<br />28b. DATE FILED BY REGISTRAR.(Mo., pay, Yr.)
<br />September 13, 2017
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Paul Earl Graham
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />September 7, 2017
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Wood River, Nebraska
<br />(Yrs.)
<br />75
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />April 23, 1942
<br />7. SOCIAL SECURITY NUMBER
<br />505-52-3179
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />CHI Health St. Francis
<br />❑ ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY CF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Wood River
<br />y: FUI
<br />0
<br />a
<br />CO to
<br />• A<
<br />Co m
<br />D
<br />O Z
<br />O C
<br />3
<br />N
<br />O
<br />tU
<br />a
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />9g. INSIDE CITY LIMITS
<br />0 YES ® 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 />Elaine Etta Graham
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Don Graham
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Alice Clark
<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 />Elaine Etta Graham
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />0 Cremation 0 Entombment
<br />❑ Removal Q Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smydra
<br />16b. LICENSE NO.
<br />1454
<br />16c. DATE (Mo., Day, Yr.)
<br />September 12, 2017
<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 UNG 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 />1_1 CAUSE OF DEATH (See instructions and examples)
<br />1>M. 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 />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a/ Aspiration Pneumonia
<br />disease or condition rsuding
<br />APPROXIMATE INTERVAL <.
<br />onset to death
<br />1 Week
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if ; b)Esophageal Motility Disorder
<br />any, leading to the cause fitted
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />$disease or injury that initiateda..
<br />the events resuIUngin death) DUE TO, OR AS A CONSEQUENCE OF:
<br />usT d)
<br />onset to death
<br />1 Month
<br />onset to death
<br />onset to death
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Congestive Heart Failure
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />feted by: CERTIFIE
<br />00000:
<br />$ i$ a $ rAr
<br />111
<br />= m ' o m mr
<br />I; c d
<br />111
<br />I Ac am r
<br />B
<br />n � n
<br />Et, g
<br />g
<br />0 3
<br />3
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />Accident Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />0 ❑
<br />0 Suicide 0 Could not be determined
<br />0 Pedestrian
<br />❑ 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?
<br />❑YES ONO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY- STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be completed by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />23a. DATE Of DEATH (Mo., Day, Yr.)
<br />September 7, 2017
<br />To be completed by
<br />CORONERS PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SINNED (Mo., Day, Yr.)
<br />September 11, 2017
<br />23c. TIME OF DEATH
<br />03:03 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />23d. 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 />John A. Wactoner, MD
<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 cause(s) stated. (Signature and Tide)
<br />25. Oto TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES Il NO 0 PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />John A. Wagoner, MD, 800 N Alpha Street, Grand
<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 />Island, Nebraska, 68803
<br />28a. REGISTRAR'S
<br />SIGNATURE
<br />28b. DATE FILED BY REGISTRAR.(Mo., pay, Yr.)
<br />September 13, 2017
<br />
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