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silt 41 i'r teiri�iil) 11(IEdleiti- pit NI �.-` ,,.r�$)1,S64% ,..t+ , ))feint isaT!y; ,:± t)5i itltt.';,t49fi lobe; aa,4fm9 X53 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 4/21/2020 LINCOLN, NEBRASKA 202004203 SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENTS NAME (First, Middle, Last, Suffix) Daniel Joseph Luton 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Columbus, Nebraska 5a. AGE - Last Birthday (Yrs.) 61 Sb. UNDER 1 YEAR 2. SEX Male Sc. UNDER 1 DAY MOS. DAYS HOURS MINS. 20 04957 3. DATE OF DEATH (Mo., Day, Yr.) April 14, 2020 6. DATE OF BIRTH (Mo., Day, Yr.) July 21, 1958 7. SOCIAL SECURITY NUMBER 505-82-7021 eb. FACILITY-NAME(Ifnot Institution, give street and number) CHI Health St. Elizabeth 8c. CITY OR TOINN OF DEATH (Include Zip Code) Lincoln 68510 8e. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/Outpatient ❑ DOA OTHER 0 Nursing Home/.1C 0 Decedent's Home ❑ Other (Specify) I8d. COUNTY OF DEATH Lancaster aspics Facility 9e. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 1203 W. Division St. 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married 0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown 9b. COUNTY Hall 9e. CITY OR TOWN Grand Island Be. APT. NO. W. ZIP CODE 68801 Sg.1NSIDE0TV LIMITS; ® YES ❑ NO 1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Mary Reed 11. FlTHER'S•NAME (First, Middle, Last, Suffix) Daniel Martin Luton 13. EVER IN U.S. ARMED FORCES? Give dates of service N Yes. (Yes, No, or Unk) Yes 12/02/ 975-10/05/1976 112. MOTHER'S -NAME (First, Middle, Maiden Surname) Marcella Elizabeth Richter 14a. INFORMANT -NAME Mary Luton 14b. RELATIONSHIP TODECEDENT Wife 15. METHOD OF DISPOSITION ❑'Burial ❑Donation El Cremation 0 Entombment ❑`Removal ❑ Other (Specify) 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) April 17,2020........ 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon STATE Nebraska 17a. FUNERAL. HOME NAME AND MA LINO ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events- -diseases, injuries, or complicatlons4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines If necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Systolic Heart Failure dlsaase or condition resulting In death) _... Sequentially list conditions, If any,leading to the causelisted on aIle a.... 17b. Zip Code 68801;. APPROXIMATE INTERVAL onset to death Months DUE TO, OR AS A CONSEQUENCE OF: b) Non -ischemic Cardiomyopathy DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE C) (disease or !Nary that the events resulting in death) LAST DUE TO, OR AS A CONSEQUENCE OF: d) onset to death Months onset to death 18. PART II.OTHER:SIGNWFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I Non-traumatic Rhabdomyolysis 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES E NO 20. IF FEMALE.. 0 Not pregeant within pest year Pregnant at time of death':. 0 Net pregrilent, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death ❑__.Unknown If pregnant within the pest year 21a. MANNER OF DEATH E Natural 0 Homicide 0 Accldem 0 Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY 0 Delver/Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? .. ❑ YES E NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 225x DATE OF INJURY (Mol, Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑.NO,, 22e. DESCRIBE HOW INJURY OCCURRED 22f, LOCATION OF INJURY STREET & NUMBER, APT.NO. 23a. DATE OF DEATH (Mo., Day, Yr.) April 14, 2020 23b. DATE SIGNED (Mo., Day, Yr.) April 16.2020 CITYITOWN 23c. TIME OF DEATH 01:26 PM 13d. To (he best of My knowledge, death occurred at the time, date and place and due h the cause(s) stated. (Signature and Title) Jessica D. Taylor, PA -C STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH ZIP CODE 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and/or Investigation, in my opinion deeM aecurred at :. the time, date and place end due to the cause(s) stated. (Signature and Title) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ENO 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES '❑ NO 0 PROBABLY E UNKNOWN 27. NAME, TIME AND t DDRESS OF CERTIFIER (Type or Print Jessica D. Taylor, PA -C, 555 South 70th Street Lincoln, Nebraska, 68510 28a. REGISTRAR'S SIGNATURE 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) April 17, 2020 i