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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 />0134 d'S"7
<br />DATE OFISSUANCE 20 V 5 ELS FOS ER
<br />7/25/2019 ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />LINCOLN, NEBRASKA
<br />1
<br />1. DECEDENTS -NAME (First, Middle, Last, SufRx)
<br />Diane Joyce Irwin
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />July 20, 2019
<br />6. DATE OF BIRTH (Mo. Day, Yr„)
<br />4. CITYANOSTATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIA SECURITY NUMBER
<br />508-48-2493
<br />Sc, AGE. Last Birthday b. UNDER 1 YEAR
<br />MOS. DAYS
<br />(Yrs.)
<br />`d Sb. FACILITY -NAME (If not Institution, give street and number)
<br />Gran Island Lakeview Care & Rehabilitation Center
<br />ac. CITY OR TOWN OF DEATH (Include_ Zip Code)
<br />Grand island 68801
<br />9e. RESIDENCE -STATE
<br />Nebrask.
<br />9d. STREET AND NUMBER
<br />713 North Sycamore Av_e
<br />75
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />ERIOublatient
<br />❑ DOA
<br />Sc, UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />November 27, 1943
<br />OTHER Mi Nursing Home/LTC
<br />[I Decedent's Home
<br />❑ Other (Specify)
<br />Ed. COUNTY OF DEATH
<br />Hall
<br />Sb. COUNTY
<br />Hall
<br />So. CITY OR TOWN
<br />Grand Han.
<br />lob. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Merited, but separated; 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Lest, Suffix)
<br />Walter Bernth
<br />S EVER IN U.S. ARMED FORCES? Glve dates of service if Yes.
<br />(Yes, No, or Unit.) Nq
<br />16. METHOD OP DISPOSITION
<br />0 Burial Q Donation
<br />.E ® Cremation 0 Entombment
<br />❑ Removal O Other (Specify)
<br />10b. NAME OF SPOUSE (First,
<br />Robert Irwin
<br />14a. INFORMANT -NAME;
<br />Roberijnfin
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />APT. NO.
<br />W. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />Middle, Last. Suffix) If wife, give maiden name
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Wilma Porkny
<br />18b. LICENSE NO.
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />18e. DATE (Mo., Day, Yr.)
<br />Jul 22 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL NOME NAME AND MA LING ADDRESS (Street, City or Town, State)'
<br />Adel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />a,
<br />{
<br />CITY I TOWN
<br />Gibbon
<br />STATE
<br />Nebratka
<br />17b. Zip Cods
<br />88801
<br />CAUSE OF DEATH (See Instructions and examples)
<br />-1a. PART 1. Enter the chain of events- -diseases, Injuries, or complications -that directly caused lite death. DO NO emertermhwl events such as cardiac arrest,
<br />rwpiratery Inst, Or veMriouter fibrillation without showing the etiology. DU NOT A88RESIATE. Ender only ens cause on a Ilm. Add additional lines If neeesesry.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Dementia
<br />disease or condition resulting
<br />in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />N"IFOINNITiataonrlxwas it b)Cerebrovascuiar Disease
<br />any, ipeding to the Cause listed
<br />on line a
<br />J
<br />APPROXIMATE. INTERVAL.
<br />onset to death
<br />2 Years
<br />onset to death
<br />5 Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />(dlasermorkdttry thet Initietee
<br />the MAIM* reeualng:m Wath)
<br />LAST
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />onset to death"
<br />5 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />Seizure Disorder
<br />420. IF FEMALE:
<br />® Net pregnant Within ails) year
<br />❑ Pregnant at dim o/ death
<br />Not prefina t,:btn pdgnaM.wahin 42 days of death
<br />❑
<br />Not
<br />pntpnam, but
<br />1:3 Unknlwim if pieenant43 days SeI year before death
<br />ptbgnaM within the pest year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORI{?
<br />p YES ❑ NO
<br />2�1,e1. MANNER OF DEATH
<br />191 Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />❑ Suicide ❑ Could net be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operate,
<br />❑ Passenger
<br />0 Pedestrian
<br />Other (specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ Yes IE No
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />O YES ri1 NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE Of DEATH?
<br />❑ YES ❑ NO
<br />22e. 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 />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />CITY/TOWN
<br />July 20, 201''9
<br />23b. DATE SIGNED (Mo., Day, Yr,) 23c. TIME OF DEATH
<br />1 gJuly 22. 2019 05;15 AM
<br />3d. To the best of my knowledge, death occurred at the time, dale and place
<br />I
<br />and due to the causels) Hated. (slpnaturs and Title)
<br />William Landis, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES El NO 0 PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF' CERTIFIER (Type or Print
<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 examinstion and/or invertMation, M my opinion death occurred at
<br />the time, date and place and due to the cause(*) stated. (signature and Title)
<br />26a. HAS ORGAN OR;TISSUE :DONATION BEEN CONSIDERED?
<br />El YES NO
<br />28b. WAS CONSENT GRANTED? 'r
<br />Not Applicable if 28e is NO 0 YES NO
<br />Witlisrn Landis, MD., 2444 W. Faidley Avenue, Grand Island, Nebraska, 88803.
<br />28a, REGISTRAR'S SIGNATURE :
<br />28b. DATE FILED BY REGISTRAR (MO, Day. Yr.)
<br />July 23, 2019
<br />U-1
<br />CO
<br />
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