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<br />�E OF NEBRAY SK�AoA '�i
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<br />WHEN THIS r'' 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 />1/2/2020
<br />LINCOLN, NEBRASKA
<br />2 TRUSSELL TFOSLER
<br />2 0 `� 0 0 2 9 A 5
<br />DEPARTMENT OF HEALTH R
<br />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 />David Ellyson Harris
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr)
<br />December 22, 2019
<br />4. CITY AND STATS OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />San Francisco, California
<br />7. SOCIAL SECURITY NUMBER
<br />575-32-4992
<br />es
<br />er
<br />,3
<br />m
<br />1,
<br />Sc. CITY^N '.--J.•i: tircitaati .."cl
<br />to
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Hesith St. Francis
<br />Grand Island 68803
<br />Se. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />5a. AGE - Last Birthday
<br />(Yd!
<br />86
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />® ER/outpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />8. DATE OF BIRTH (Mo ;;Day, Yr,);.
<br />February 27, 1
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />INTY ,-te f)FAT}r
<br />Hall
<br />9d. STREET AND NUMBER
<br />2906 Idaho Ave
<br />10a. MARITAL STATUS AT, TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, butsepatated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />933
<br />0 Hospice Facility
<br />9g. INSfDE CIVt' UMITS
<br />® YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Jean Eileen Hueftle
<br />12. MOTHER'S -NAME (First, Middle,
<br />Alfred Richard Harris 1 Arel T Ellyson
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes,' No or unk,) Yes 03/02/1953-03/01/1955
<br />14a. INFORMANT -NAME
<br />Jean Eileen Harris
<br />Maiden Surname)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />® Cremation 0 Entombment
<br />❑ Removal 0 Other {Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<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 />CAUSE OF DEATH (See instructions and examples)
<br />1f L. PART: 1. lir the chain of events- -diseases, injures, 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 if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Cardiac Arrest
<br />disease or condition resulting
<br />Sri _desthl
<br />Sequentially lint colfflhione, if
<br />any, leading to the cause Rated;:
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury that initiated
<br />Ow events rilg3n death) ;.
<br />LAST
<br />16c. DATE (Mo., Day, Yr.)
<br />December 24, 2019
<br />STATE
<br />Nebraska
<br />1713. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL <.
<br />onset to death
<br />Minutes
<br />.
<br />b) Ventricular Fibrillation
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Acute Myocardial Infarction
<br />nna.! of lasttt
<br />Minutes
<br />onset to death
<br />Hours
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)Atherosclerosis
<br />onset to death
<br />Years
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART 1.
<br />20. IF FEMALE:
<br />0 Not pregnant within put year
<br />❑ Pregnant at time of death
<br />© Ncl pregnant,. but pregnant within 42 days of death
<br />❑ Not pregnant, but
<br />pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant withtn.the past year
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could tiet bo determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑ Passenger
<br />Pedestrian
<br />0 Otbet (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES Ix1 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 />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURYAT WORK?
<br />❑YES ONO
<br />22b. TIME OF INJURY
<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 8 NUMBER, APT.NO.
<br />CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 22 2019
<br />u.S,:r YGk�CL ,•\r., V-A, ,..j . :i@,c..
<br />December 23, 2019 04:22 PM
<br />9d. To the best of my knowledge, death occurred at the tkne, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Zachary W_ Meyer, MD
<br />STATE •ZIP CODE
<br />24e. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />tr Cn 2.c.•n •. V- u -\AN rNr pPn•:.^I A[»Cal M1C^D:
<br />C z o 24e. On the basis of examination and/or investigation, In my opinion death occurred at
<br />g i the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />12
<br />8
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION: BEEN CONSIDERED?
<br />0 YES Et NO ❑ PROBABLY 0 UNKNOWN 0 YES ® NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Zachary W. Meyer, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska 68803
<br />$a.;REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO 0 YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yt.)
<br />December 26, 2019
<br />
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