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<br />! STATE OF NEBRASKA• tls3 .:: dldtt. t 4449SSlYI4SD4+x > ac2tt'i44Wrtt a e>Xrx4444r1S9I:fGte x. yknrJnArtaa g.h.'tb>'z1+!a4l; u b,>
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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 OF ISSUANCE
<br />2019078RUSSELL FOSLER
<br />5 2. INTERIM 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 />10/12/2018
<br />UNCOLN, NEBRASKA
<br />L
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Donald Paul Rock
<br />4. CITY ANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />St. Libory, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507-30-9322
<br />5a, AGE - Last Birthday
<br />(Yrs.)
<br />$ 8b. FACILITY -NAME (If not Institution, give street and number)
<br />a>
<br />g CHI Health St. Francis
<br />2-7 8c. CITY OR TOWN CF EAT11 ;:. Iu t Zip Cada:
<br />Grand. island 68803
<br />v
<br />d
<br />m
<br />IS
<br />Iv
<br />at
<br />of
<br />m
<br />«r3 Enter the UNDERLYING CAUSE
<br />(disease or injury that initiated':
<br />ttte events resuakig in death)
<br />LAST
<br />a,
<br />r
<br />OJ
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />408 W 12th St
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated; 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (Firttt, Middle, Last, Suffix)
<br />Maurice Rock
<br />89
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />PAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />ER/Outpatient
<br />❑ DOA
<br />9a CtTY OR TOWN
<br />Grand island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />September 26, 2018
<br />6. DATE OF BIRTH (Mo., DIM Yr.)
<br />May 22, 1929
<br />OTHER ❑ Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />i ou. COUNTY O.= DEATH
<br />Hail
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS'
<br />® YES 0 NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden naPne
<br />Margie Kaumans,
<br />12. MOTHER'S -NAME (First,
<br />Mildred Miller
<br />Middle, Maiden Surname)
<br />13. EVER IN U.S, ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Uelc) NO
<br />15. METHOD OF DISPOSITION
<br />Burial 0 Donation
<br />❑ Cremation ❑ Entombment
<br />❑;Removal ;❑ Ogler (Specify)
<br />14a. INFORMANT -NAME ;>
<br />Margie Rock
<br />16a. EMBALMER -SIGNATURE
<br />Matthew T. Mvers
<br />16b. LICENSE NO.
<br />1411
<br />14b. RELATIONSHIP:: TO DECEDENT:.
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />October 1, 2018
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Cemetery
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Livinaston-Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17b, Zip Code
<br />68803
<br />CAUSE OF DEATH (See instructions and examples)
<br />1e. PART I. Enter the chain of events- diseases, injuries, or complications -that directly caused the death, DO NOT enter temdttel events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a lino. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Aspiration Pneumonia
<br />disease or condition resulting
<br />Seque tiauythtt conditiotis, if
<br />any, leading to the cause IyteQ:
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Chronic Respiratory Failure With Hypoxia
<br />LAIL 10, OR Aa A L,ONSEQUtel .r_ Oh:
<br />c) End Stage Chronic Obstructive Pulmonary Disease
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />d) Life Long Tobacco Use Disorder
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Parkinson's Disease, Severe Dementia
<br />w
<br />20. IF FEMALE:
<br />❑ Not pregnantwi thin past year
<br />❑ Pregnant at time of death
<br />❑ 5 pregnant; but pfegnant within 42 days d death
<br />❑ Diet pregnantut pngnam 43 days to 1 year before death
<br />0
<br />Unknown Pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />0 Suicide 0 COuld not be determined
<br />21b, IF TRANSPORTATION INJURY
<br />© Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />Other (Specify)
<br />APPROXIMATESNTERVAL
<br />onset to'death
<br />2 Days
<br />onset to oeath
<br />>5 Years
<br />onset to death
<br />>60 Years
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ Yes ®NO
<br />21c. WAS AN AUTOPSYPERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE'
<br />TO COMPLETE CAUSE OF DEATH/';
<br />O YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WQRK?
<br />❑YES ❑NO
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />Senternber.26, 2018
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />October 4, 2018 01:29 PM
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />3d. To the bast of my knowieoge, death uceunad at me t:c:e, date at;: peace
<br />and due to the cause(s) stated. (Signature and Title)
<br />Steven Husen MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES 0 NO 0 PROBABLY 0 UNKNOWN
<br />STATE ZIP CODE
<br />240. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />24a. On the oasis of examination andlor mvestigatan, m u:v opmron carat. occurnu as
<br />the time, date and place and due to the causa(s) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ 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 />Steven Hu. sen, MD, 2116 W Faidley #400, Box 9802, Grand. Island, Nebraska, 68803
<br />28a. REGISTRAR'S
<br />SIGNATURE
<br />,r
<br />670.
<br />28b. DATE FILED BY REGISTRAR Mo., Day, Yr.)
<br />October 9, 2018
<br />
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