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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§DDPPSIVAYZ J;NTA RECORDS
<br />DATE OF ISSUANCE
<br />9/19/2017
<br />LINCOLN, NEBRASKA
<br />201905195
<br />202000811
<br />A.ace
<br />STANLEY S. OOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />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 />Paul Earl Graham
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />September 7, 2017
<br />4. CITY: AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Wood River, Nebraska
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />75
<br />513. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo.
<br />April23, 1942
<br />Day, Yr.)
<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 />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />0 Hospice Facility
<br />8c. CITY OR TOWN OF DEA71 flnclude Zip Code1
<br />Grand Island. 68803
<br />as. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Wood River
<br />I8 . COUNTY CF ^_ ?H
<br />Hall
<br />9d. STREET AND NUMBER
<br />13270 W. Wood River Road
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />9g. INSIDE CITY LIMITS
<br />❑ YES I NO
<br />105. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed ❑ Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, a Middle, Last, Suffix) If wife, give maiden name;
<br />Elaine Etta < Graham
<br />11. FA'THER'S -NAME (First, Middle, Last, Suffix)
<br />Don Graham
<br />1 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Alice Clark
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, Ot Unk4 No
<br />14a. INFORMANT -NAME
<br />Elaine Etta Graham
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />Removal >❑ Oilier (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />16b. LICENSE NO.
<br />1454
<br />16c. DATE (Mo., Pay, Yr.)
<br />September 12, 2017
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />PART I. Enter the 4hain of events- -diseases, injuries, or complicatlonsdhat 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 it necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Aspiration Pneumonia
<br />cunditicn
<br />In death)
<br />Sequentially fat eotubeam; If
<br />any, leading to the 'silage listed.:
<br />on linea.
<br />Enter the UNDERLYING CAUSE
<br />irllseaaa or injury that Initiated:
<br />the events resulting in death)
<br />IAS[.1:.
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />1 Week
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Esophageal Motility Disorder
<br />onset to death
<br />1 Month
<br />E'UE TO; OF AS A CCNSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART 1.
<br />Congestive Heart Failure
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES E NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />0 Net pregnant, put prapnam 49 days to 1 year before death
<br />❑ Unknown it pregnant Within the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ HornIclde
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />0 Driver/Operator
<br />0 Passenger ❑ YES ® NO
<br />0 Pedestrian
<br />Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />L.i Y€S ❑ NQ
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />. Shia OF aZIATii (Mo., Lay, Yr.)
<br />M SeAtember 7, 2017
<br />231>. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Se tember 11. 2017 03:03 AM
<br />S 0 O •3d. To the best of my knowledge, death occurred at the time, date and place
<br />0Wl and due '.i the commis) stated. (SlgTitle)
<br />and kf)
<br />Fo Y :
<br />CITY/TOWN
<br />IOn A. Wagoner, MD
<br />5. DH! TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES NO 0 PROBABLY 0 UNKNOWN
<br />>
<br />�+
<br />6a�
<br />Ey,;�
<br />s W z 24e. On the basis of examination and/or investigation, in my opinion death mooned et
<br />E 3 the time, date and place and due to the cause(s) stated. (Signature and Tae)
<br />g `a
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES ®NO
<br />STATE
<br />24a. DAte SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO 0 YES 0 ;C
<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. REGISTRAR'S SIGNATURE
<br />Exhibit "A"
<br />28b. DATE FILED BY REGISTRAR (Mo., Day,
<br />September 13, 2017
<br />
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