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<br />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 OFISSIJANCE RUSSELL FOSLER
<br />O O
<br />10/4/2019 6 ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND: HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Ts
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Gordon Thomas Hazen
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Bangor, Maine
<br />7. SOCIAL SECURITY NUMBER
<br />479-64-0938
<br />5a AGE -Last Birthday
<br />(Yrs.)
<br />70
<br />O 8b. FACILITY -NAME (If not Institution, give street and number)
<br />itb
<br />12,
<br />Bruen W)ed;c?I Center West
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />E
<br />.c
<br />.2
<br />a
<br />m
<br />Lincoln 68502
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />1428 Ruby Avenue
<br />9b. COUNTY
<br />Hall
<br />sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 7, 2019
<br />6. DATE OF BIRTH (Ma, Day, Yr.)
<br />June 5, 1949
<br />8a. PLACE OF DEATH
<br />HOSPITAL El Inpatient OTHER 0 Nursing Home/LTC
<br />ER/Outpatient 0 Decedent's Home
<br />Dc f-1 rte. r4s a
<br />8d. COUNTY OF DEATH
<br />Lancaster
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />❑ Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, hut separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Lee Ann Proctor
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) f 12. MOTHER'S -NAME (First, Middle,
<br />Carroll Arthur Hazen
<br />Marion Vesta Grant
<br />Malden Surname)
<br />13. EVER IN U.S.ARMED>FORCES? Give dates of service If Yes.
<br />(Yes, No, or Urk.) Yes i' 10/31/1968-10/30/1978
<br />15. METHODOF DISPOSITION
<br />❑ Burial 0 Donation
<br />® Cremation ❑ Entombment
<br />❑ Removal :❑ Other (Specify)
<br />14a. INFORMANT -NAME
<br />Lee Ann Hazen
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<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 />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />$, PART 1. Enter the -chain of eyans--diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />tatipiratory area, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Tines N necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Asphyxia
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially aatconditions, N b)Ligature (self) Garroting Using Towels And Drain Grate
<br />any, leading tote tdwse )bled
<br />an line it
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />'disease 0, inju T Um initlated -
<br />the events res
<br />LAST
<br />ulang:in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />August 12, 2019
<br />STATE
<br />Nebraska
<br />17b, Zip Code
<br />68801
<br />onset to death
<br />Minutes
<br />onset to death
<br />onset to death'
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES [] NO
<br />20. IF FEMALE:
<br />0 Not pregnant within pest year
<br />❑ Pregnant at time of death
<br />0 Not pregnant> but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Utdcndwn if pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />August 6, 2019
<br />22d. INJURY AT WORK?
<br />O YES El NO
<br />21a. MANNER OF DEATH
<br />0 Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />El Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />03:30 PM
<br />21b. IF TRANSPORTATION
<br />❑ Driver/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />Othet(Specify)
<br />INJURY
<br />21c. WAS AN AUTOPSY PERFORMED? S'
<br />El YES ❑ NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />®YES 0 N
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />Butler County Detention Center
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />Decedent inmate tied a towel around his neck and also to
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />451 N 5th Street, David City
<br />23a. DATE OF DEATH (M1., Day, Yr. )
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<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 />the cell's floor drain intentionally cutting off his airway.)
<br />STATE
<br />Nebraska
<br />24e. DATE SIGNED (Ma, Day, Yr.) 24b. TIME OF DEATH
<br />.: 5 <<
<br />?i2,, Z616 0E:O7 r M
<br />�i Y 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />$ J August 7.2019
<br />I
<br />05:07 PM
<br />B 24e. On the basis of examination and/or investigation, M my opinion death occurred at
<br />o 1
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />6, Julie L. Reiter, Butler County Attorney
<br />ZIP CODE
<br />68632
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ❑ NO 0 PROBABLY El UNKNOWN
<br />28a. HAS ORGAN OR TISSUE DONATION; BEEN CONSIDERED?
<br />❑YES ElNO
<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 />Julie L. Reiter, Butler County Attomey, 451 5th Street, P.O. Box 87, David City, Nebraska, 68632
<br />28a. REGISTRAR'S SIGNATURE
<br />iCtCL� l-�.
<br />28b. DATE FILED BY REGISTRAR
<br />August 27, 2019
<br />a, Day, Yr.)
<br />1
<br />
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