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<br />;y,,4�, /r 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 LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />0 0 0 0 INTERIM ASSISTANT STATE REGISTRAR
<br />7/19/2018 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 />Wilburn Glenn Donahoo
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Aurora, Nebraska
<br />$ 7. SOCIAL SECURITY NUMBER
<br />508-30-3724
<br />5a, AGE - Last Birthday
<br />(Yrs.)
<br />85
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />July 10, 2018
<br />6. DATE OF gKRTH (Mo. Day, Yr.)
<br />February 7, 1933
<br />44 8b. FACILITY -NAME (If not Institution, give street and number)
<br />Park Place -A Golden Living Center
<br />g, 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />0 Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Hall
<br />` 9d. STREET AND NUMBER
<br />4128 Allen Dr.
<br />g 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />v
<br />d ❑ Married, but separated: ❑ Nfidowed 0 Divorced 0 Unknown
<br />e11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Clyde Wilburn Donahoo
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS"
<br />M YES ❑ NO
<br />lab. NAME OF SPOUSE (First, Middle, Lest, Suffix) H wife, give maiden name
<br />LaDonna Jean Gulzow
<br />12. MOTHER'S -NAME (First, Middle, Maiden Sumame)
<br />Adelaine Pearl Karr
<br />}$ EVERIN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes No, or Unk) Yes 04/09/1952-03/11/1954
<br />I15. M£THOD OF 1'S*SPOStTiON
<br />g ❑ Burial 0 Donation
<br />S El Cremation 0 Entombment
<br />„so❑ Oth l P fy)
<br />❑Removal er S eel
<br />14a. INFORMANT -NAME
<br />LaDonna Jean Gulzow
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />165. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />1613. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />July 13, 2018
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park CrematOry
<br />f 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Livinaston-Sondermann Funeral Home. 601 N. Webb Road. Grand Island, Nebraska
<br />9
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />IL PART 1. Enter 11* chain ofevents-diseases, Injuries, or complications -that directly caused the death. 00 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) Respiratory Failure
<br />disease or condition resulting
<br />In death)::::
<br />SetProMialty Eist conditioas, d
<br />any, Fading to the cause Ibted
<br />on lire a
<br />0
<br />S Enter the UNDERLYING CAUSE
<br />'a (disease er Maury that Endiatad::.
<br />:9! sulorngm
<br />e.
<br />the events re
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)End Stage Renal Disease
<br />STATE
<br />Nebraska
<br />17b. Zip Code .
<br />68803
<br />APPROXIMATE' INTERVAL
<br />onset to death
<br />Immediate
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Coronary Artery Disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d) Dementia
<br />onset to death
<br />Years
<br />onset to death
<br />Months
<br />+t+ 18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Patient Declined Medically And Transitioned To Hospice And Passed Away
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES El NO
<br />tr0. IF FEMALE:
<br />0 Not pregnant within past year
<br />t
<br />v 0 Pregnant at time of death
<br />Nat Pregnant, but pregnant within 42 days of cream
<br />© Not pntgnftInd pr9nant.43 days tot year before firth
<br />0 Uhkneym H
<br />priorities within the pest year
<br />21a. MANNER OF DEATH
<br />El Natural 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />❑ Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />El Driver/Operator
<br />❑ Passenger
<br />Pedestrtan
<br />Otho (Specify)
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />❑ YES El NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />,Q 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />U1
<br />c
<br />22d. INJURY AT WORNC?
<br />u 0 YES 0 Nth
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, ate. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />v 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />JUIY 10, 2018
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />July 11, 2018
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />12:40 PM
<br />3d. To the best of my knowledge, deathoccurred at the time, date and place
<br />and due to die cause(s) stated. (Signature and Title)
<br />Michael A. Donner, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES El NO ❑ PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, M my opinion death occurred at
<br />the time, date and place and due to the cause(e) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE • • ATION 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 />Michael A. Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />8& REGISTRAR'S SIGNATURE
<br />,...� -�-
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) , I
<br />July 17, 2018
<br />
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