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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 le
<br />1111812019 ANCE 2 O 4 Q O ry Q 2� RUSSELL E REGISTRAR
<br />a7 I a7 ' 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 />LINCOLN, NEBRASKA
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />James Edward Dealey
<br />4. CITY AND STATE ORTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Post, Texas
<br />7. SOCIAL SECURITY NUMBER
<br />506-40-2192
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />84
<br />lib. FACILITY -NAME (If not Institution, give street and number)
<br />Grand Island Lakeview Care & Rehabilitation Center
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November W. 201'
<br />6. DATE OF BIRTH (Msf., Day;Yf.).
<br />June 30, 1935"
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />0 Hospice Facility
<br />t
<br />d
<br />9d. STREET AND NUMBER
<br />651 Groff £::rte
<br />10a. MARITAL STATUS AT TIME OF DEATH ®Married 0 Never Married
<br />0 ❑ Married, but separated ❑ Widowed ❑ Divorced 0 Unknown
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />8a. RESIDENCE -STATE
<br />Nebraska
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9b. COUNTY
<br />Hall
<br />1:
<br />u
<br />11. FATHER'S -NAME (Fust, Middle, Last, Suffix)
<br />Joseph Greg Dealev
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Urik.) Yes °: 04/30/1958-04/29/1960
<br />15. METHOD OF DISPOSITION
<br />❑'Burial 0 Donation
<br />® Cremation 0 Entombment
<br />❑;Removal : 0 Other (Specify)
<br />sc. CITY OR TOWN
<br />Grand Island
<br />19e. APT. NO. 1 Pr. ZIP CODE I 9g. INSIDE CITY -LIMITS
<br />I I 38C.j1 l (o"I YE3 Li 1.0
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, gide maiden name
<br />Lorna Jean Kumke
<br />14a. INFORMANT -NAME
<br />Lorna Jean Dealev
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Helen Anna Oye
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street, Grand Island. Nebraska
<br />6b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse .
<br />18c. DATE (Mo„ Day, Yr.)
<br />November 12, 2019
<br />STATE
<br />Nebraska
<br />17b. Zap Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART L Etter the chair of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter tern (nal events such as cardiac arrest,
<br />respiratory arrest, M ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one causeon a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) End Stage Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure
<br />disease or condition resuhing
<br />M dseth)
<br />SeQuentially ast condleons, W
<br />any, leading to the cause Sated:
<br />on line a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Tobacco Use Disorder
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNOERLYINO CAUSE .i
<br />(disease or injury that Initiated
<br />the events molting in death);.
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />Severe Vascular Dementia, Chronic Congestive Heart Failure, Chronic Cerebrovascular Disease, Arteriosclerotic Cardiovascular
<br />Disease
<br />120
<br />IF FEMALE:
<br />0 Not pregnant within past year
<br />t
<br />❑ Pregnant at ems of death
<br />•3F 0 Nor pregnMm, but pregnant within 42 days of deatlr
<br />0 Na pregnd.i ,;bw P7vipani ncvs tc t , :ar !_tear .k_:;.
<br />0 Unknown ftpregnaatir. nit Wet year
<br />O
<br />•
<br />v
<br />c
<br />e
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d, INJURY AT WORK?
<br />AYES 1:1 NO
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />❑ Sui^.ide 0 Could net Do determined
<br />22b. TIME OF INJURY
<br />APPROXIMATE INTERVAL:;
<br />onsetto death
<br />10 Years
<br />onset todsa*h
<br />60 Years
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />KI
<br />❑ YES NO
<br />211x IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />0 Driver/Operator
<br />0 Passenger
<br />❑ Pedestnan
<br />1 int;/S,.Ylfyl
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />i--1 YES LJ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LCCA tier+ yr nv.j:i is i ., i iktE
<br />0
<br />... 1"r
<br />5
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 0, 2019
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />AlnN'omi'tpr 11. 7010
<br />23c. TIME OF DEATH
<br />117.5R am
<br />3d. To the rest of my knowledge, death occurred at the tine, date and place
<br />and due to the causes) stated. (Signature and Tile)
<br />Steven KI. en, MD
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis or examination and/or investigation, M my opinion death occurred at
<br />Me time, date and place and due to the causes) stated. (Signature and TWO
<br />25. DO TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES ❑ NO 0 PROBABLY ❑ UNKNOWN
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES ]NO
<br />25b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a Is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR {Mo., Day, Yr.)
<br />November 14, 2019
<br />0
<br />CIO
<br />(A)
<br />
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