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<br />STATE OF NEBRASKA
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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 LEGA DAP S jO4Y6t x T RECORDS
<br />trZDATE OF ISSUANCE
<br />201905195
<br />9/19/2017
<br />LINCOLN, NEBRASKA
<br />ate
<br />STANLEY S. EDOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE QF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Paul Earl Graham
<br />4, CITY>AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Webt River,iNebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-52-3179
<br />8b FACILITY -NAME (if not institution, give street and number)
<br />CHI Health St. Francis
<br />it 8c. CITY OR TOWN OF DEATH (include Zip Code)
<br />Grand Island 68803
<br />W
<br />2
<br />u.
<br />LL
<br />a
<br />9a RESIDENCE -STATE
<br />Nebraska •
<br />9d. STREET AND NUMBER
<br />13270 W. Wood River Road
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First; Middle, Last, Suffix)
<br />Don Graham
<br />13> EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) NO
<br />5a. AGE- Last Birthday
<br />(Yrs.)
<br />75
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />© ER/Outpatient
<br />❑ DOA
<br />DAYS
<br />9c. CITY OR TOWN
<br />Wood River
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />September 7, 2017
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />April 23, 1942
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />COUNTY OF DEATH
<br />Hal
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />9g. INSIDE CITY LIMITS"
<br />❑ YES ® NO
<br />10b. NAME OF SPOUSE (First, : Middle, Last, Suffix) If wife, give maiden name
<br />Elaine Etta Graham
<br />I< 12. MOTHER'S -NAME (First,
<br />Alice Clark
<br />14a. INFORMANT -NAME
<br />Elaine Etta Graham
<br />Middle, Maiden Surname)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSmoN
<br />I Burial 0 Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Rernovai ;❑ Other(Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smydra
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All' Faiths FuneralHome. 2929 S. Locust Street. Grand Island.' Nebraska
<br />16b. LICENSE NO.
<br />1454
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain Of events --diseases, Injuries, or complications -that directly caused the death, DO NOT entertenninat events such as cardiac arrest,
<br />respiratory artest, or YetancUlar 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 />Cis. ,2e ,rsonditk:r, r: sostcp
<br />10 death
<br />Seciaet Barry I)st Colons, if
<br />any, lending•tr the Cadse listed
<br />on line a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Esophageal Motility Disorder
<br />16c. DATE (Mo., Day, Yr.)
<br />September 12, 2017
<br />STATE
<br />Nebraska
<br />17b - Zip 'Code
<br />68801
<br />APPROXIMATE INTERVAL.
<br />onset to death
<br />1 Week
<br />onset to d
<br />1 Month
<br />ath
<br />DUE TO; OP. AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />Sseasc or injury that inkisted::::
<br />She events resulting 3In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<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 I.
<br />Congestive Heart Failure
<br />20, IFFEMALE:
<br />❑ Not pregnant within peat year
<br />0 Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ $$pt pregnant, but pregnant.43 days to 1 year before death
<br />0 Uiihnown a pregnant wafdn the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />OYES 0 N
<br />22f. LOCATION OF INJURY- STREET & NUMBER, APT.NO.
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />Oneer/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES E NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />23a. LATE OF isEATH (iv.o., Day, Yr.)
<br />Seatember 7, 2017
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Se tember 11, 2017 03:03 AM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(,) stated. (Signature and Title)
<br />John A Weiioner, MD
<br />5. D)D:TOBAC.CO USE QONTRIBUTE TO THE DEATH?
<br />❑ YES NO ❑ PROBABLY 0 UNKNOWN
<br />STATE ZIP CODE
<br />2 24a. DAT* SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />1.a g
<br />J
<br />ig
<br />s ,3 24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />g p the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />~rgJ
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES El 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 />John A. Wagoner, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />28a. REGISTRARS SIGNATURE J - 4z
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 13, 2017
<br />
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