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aowIlmfgaffic Rte (ifi3b t3tl am'mvii, 1111 $) I eeaaFt i ; 013d/?Ct4 �tY�/&x44tM�4rNst uc§g861ttitiliDiJac<a e8�tt'/�Ar re!6!y).GASRz. • : +9zrG44HAA�re P 1 it 0040"1411 4�(' nQSfFShy )t0)0tti�up1D11 @ Oh l 1 aitleslro3$1011069040iIO'e/ 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 , 9 DATE OF ISSUANCE O RUSSELL FOSLER 10/17/2019 VO O O ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Perry Lew Ulmer 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH York, Nebraska 7. SOCIAL SECURITY NUMBER 506.58-7821 5a AGE - Last Birthday (Yrs.) 72 8b. FACILITY -NAME (if nth kutltutlon, give street and number) 4018 Kay Ave Sit. UNDER 1 YEAR 2. SEX Male 5c. UNDER 1 DAY MOS. DAYS 8a. PLACE OF DEATH HOSPITAL 0 Inpatient 0 ER/Outpatient ❑ DOA 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand, Island 68803 8a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 4018 Kay Ave 9b. COUNTY Hall HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) September 29, 2019 8. DATE OF BIRTH (Mo., Day,Yr.) December 27, 1946 OTHER 0 Nursing Home/LTC Decedent's Home 0 Other (Specify) -78d. COUNTY OF DEATH Hall 90, CITY Oft TOWN Grand Island 0 Hospice Facility 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married 0 Marded, but separated. 0 Widowed 0 Divorced 0 Unknown 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS El YES ❑ NO 10b. NAME OF SPOUSE (First, ,Middle, Last, Suffix) ft wife, give maiden name Linda Pfeifer 11. FATHER'S -NAME (First, Middle, Last, Suffix) ' 12. MOTHERS -NAME (First, Middle, Malden Sumame) Leon Carl Ulmer Bertha Erna Griess 13, EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yea, No, or Unk.) Yes 11/01/1967-03/12/1971 15. METHODOFDISPOSITION ❑ Burial 0 Donation ® Cremation ❑ Entombment ❑ Removal ] Other (Specify) 14a. INFORMANT -NAME Kurt Ulmer 18a. EMBALMER -SIGNATURE Patricia R. Curran 180 LICENSE NO. 1092 14b. RELATIONSHIP TO DECEDENT Son 18c. DATE (Mo., Day, Yr.) October 3, 2019 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Gibbon Central Nebraska Cremation Services STATE Nebraska 17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State) Curran Funeral Chapel. 3005 S. Locust St.. Grand Island. Nebraska 1713 Zip Code 68801 CAUSE OF DEATH (See instructions<and examples) 4. PANT I. Enter ats.ohain of events- diseases, Injuries, or complications -that directly caused the. death. DO NOT enter temrinal events such as cardiac arrest, respiratory arreat or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only Are calks on a fide. Add additional fins if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Blunt Force Trauma disease or condition resulting Sequentially bat cantations, 4 any, taadinq to b e rause listed: APPROXIMATE INTERVAI onset to death Hour m ,.,. Enter then UNDERLYING CAUSE C) Fall : p tdlseair ortnJury SIM lnHiatatl ::- . a the events resulting In death) .9 LAST £ 15 .ti 1 7dt DUE TO, CR ASA CQi',SEQUENCE CF: b) Head Injury DUE TO, OR AS A CONSEQUENCE OF: onset to death Hour onset to death Hour DUE TO, OR AS A CONSEQUENCE OF: d) onset to death' 19. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1. 20. IF FEMALE: 0 Not pregnant within pest year .c - 0 Pregnant ef time of death t0 Net pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death i ❑ Unknown if pregnant within the past year w 22a. DATE OF INJURY (Mo., Day, Yr.) September 29, 2019 22d. INJURYAT'WORK7 El YES NO 21a. MANNER OF DEATH ❑ Natural 0 Homicide ® Accident ❑ Pending Investigation ❑ Suicide 0 Could not be determined 22b. TIME OF INJURY Unknown 2113. IF TRANSPORTATION INJURY 0 Driver/Operator ❑ Passenger Pedestrian Other (Specify) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? BB YES CI NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ®NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, eta (Specify) Home 22e. DESCRIBE HOW INJURY OCCURRED Decedent suffered a head injury as a result of a fall in the kitchen of his home. et 23a. DATE OF DEATH (Mo., Day, Yr.) tr a r E u it g0 + 3d. Tote twat of knowlWgs, death occurred at the thus, date and place and due to theme: uses) stead. (Signature and Mb) 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 4018 Kay Avenue, Grand Island CITY/TOWN 236. DATE SIGNED (Mo., Day, Yr.) 23e. TIME OF DEATH 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES 0 NO 0 PROBABLY ® UNKNOWN STATE Nebraska 24a. DATE SIGNED (Mo., Day, Yr.) October 2, 2019 24b. TIME OF DEATH Unknown ZIP CODE 68803 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD September 29. 2019 08:31 PM 24e. On the basis of examination and/or investigation, M my opinion death occurred at the time, date and place and due to the cause(s) sated. (Signature and Title) Williamette Gallagher, County Attorney 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ®NO 26b. WAS CONSENT GRANTED? 'r Not Applicable if 28a is NO 0 YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print WillametteGallagher, County Attorney, 231 S Locust Street, Grand island, Nebraska, 68801 29a. REGISTRAR'S SIGNATURE .n1a' 2813. DATE FILED BY REGISTRAR (M October 4, 2019 Day, Yr.) 1 oci Co W!