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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 ISSUANCEn O �1 0 O r' RUSSELL FOSLER
<br />'12/9/2019 tGr . " ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />LINCOLN, NEBRASKA AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Danford Lee Stout
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH(Mo., Day, Yr.)
<br />December 1, 2019
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506-32-8055
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />88
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health; Good Samaritan
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Kearney 68848
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />DAYS
<br />HOURS
<br />MINS.
<br />e. DATE OF BIRTH (Mo.: Day, Yr.):.:.
<br />December 10, 1930
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Buffalo
<br />9a
<br />0 Hospice Facility
<br />RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />32
<br />a
<br />., 9d. STREET AND NUMBER
<br />v 1135 S Sycamore
<br />g
<br />10a. MARITAL STATUS AT T:6FE OF DEATH ®Married ❑Nearer Married
<br />SL ,
<br />Q Married, batt sep:aratod; ❑ Widowed 0 Divorced ❑ 4riLncwn
<br />E 11. FATNER'S-NAME (First, Middle, Last, Suffix)
<br />m
<br />Levi Stout
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801ID
<br />9g. INSIDE cm( : LIMITS ".
<br />YES ❑ NO
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />fVia"i'"rt P) VUjS Helnr
<br />12. MC+4ER'S-NAME (First, Middle, Maiden Surname)
<br />Emily Verley
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes:
<br />(Yes, No. or Unk>) Yes 12/14/1948-09/09/1952
<br />14a. INFORMANT -NAME
<br />Marilyn Phyllis Stout
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal [] Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Ryan Redinger
<br />1
<br />LICENSE NO.
<br />1318
<br />16c. DATE (Mo., Day, Yr.)
<br />December 6, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Livingston -Sondermann Funeral Home, 601 N. Webb Road. Grand Island. Nebraska
<br />CITY /TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17b. ZIP Code
<br />68803
<br />CAUSE OF DEATH (See instructions and examples)
<br />8. PART i. Enter the chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular 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) Shock
<br />disease or condition mulling
<br />in death)
<br />Sequentially Net aor gieona, if
<br />any, leading to the cause hilted£
<br />on line a. _. _...
<br />Enter the UNDERLYING CAUSE
<br />(disease orinjury;that initiated
<br />the events remains in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Pulmonary Embolism
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />0)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />APPROXIMATE INTERVAL:
<br />onset to death
<br />Hours
<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 />20. IF FEMALE:
<br />0 Not piegnam within past yew
<br />0 Pregnant at time of death
<br />❑ Not pregnant, but Pregnant within 42 days of death
<br />❑ Nat pregoant, but pregnant 43 days to 1 year before death
<br />❑ Unknown If pregnant within lhe past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY
<br />22d. INJURY AT WORK?
<br />❑YEs ONO
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />21b. IF TRANSPORTATION INJURYI 21c. WAS AN AUTOPSY PERFORMED?
<br />Driver/Operator
<br />❑ YES ® NO
<br />❑ Passenger
<br />Pedestrian
<br />j other (spear)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />1 lSvee y Ma.�
<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 />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />235. DATE OF DEATH (Mo., Day, Yr.)
<br />• December 1,, 2019
<br />b, DATE SIDNED (Mo., Day, Yr.)
<br />December 4, 2019
<br />to
<br />23c. TIME OF DEATH
<br />03:28 AM
<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 TNN)
<br />Alexander Kaganas, MD
<br />244. 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 of examination and/or Investigation, In my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATIO
<br />0 YES I NO 0 PROBABLY 0 UNKNOWN 0 YES ® NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Alexander Kaganas, MD, 10 E 31st St., PO Box 1990, Kearney, Nebraska, 68847
<br />8a, REGISTRAR'S SIGNATURE
<br />BEEN CONSIDERED?
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES © NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 4, 2019
<br />
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