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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CER77FIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA QFRAR7T4ENI:OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VELREF.R.�$>1;
<br />/
<br />DATE OF ISSUANCE 202005184
<br />STANLEY S., COPPER ._�,
<br />11/06/2015 202005185 ASSISTANT STATE REGI$P ?
<br />DEPARTM �1 IA41FN AND
<br />LINCOLN, NEBRASKA NUM,4. SSIt"E5
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES �'
<br />CERTIFICATE OF DEATH .., ,,.� '_~.• N, 15 06344
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />2. SEX 3:
<br />DATE OF 6EATyJMo., pay, Yr.)
<br />Donald Lee Pontious
<br />Male
<br />October 25;"2015
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE -Last Birthday Pb.
<br />UNDER 1 YEAR
<br />6c. UNDER 1 DAV
<br />6. DATE bF BIRTH (Mo., Day, Yr.)
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />(Yrs.)
<br />Loretto, Nebraska
<br />79
<br />July 2, 1936 -
<br />7. SOCIAL SECURITY NUMBER
<br />Be. PLACE OF DEATH
<br />507-38-9839
<br />HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />C
<br />CHI Health St. Francis
<br />❑ DOA ❑ Other (Specify)
<br />it
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />8d. COUNTY OF DEATH
<br />'o
<br />Grand Island 68803
<br />Hall
<br />Q
<br />9a. RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY OR TOWN
<br />W
<br />Nebraska
<br />Hall
<br />Grand Island
<br />�
<br />9d. STREET AND NUMBER
<br />APT. NO.
<br />9f. ZIP CODE
<br />9g. INSIDE CITY LIMITS
<br />124 N. North Road
<br />68802
<br />® YES ❑ No
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />Barbara Mae Haddix
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Z
<br />d
<br />George D Pontious
<br />Fern M Giersdorf
<br />E
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />14a. INFORMANT -NAME
<br />14b. RELATIONSHIP TO DECEDENT
<br />u
<br />(Yes, No, or Unk.) No
<br />Barbara Mae Pontious
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />16a. EMBALMER -SIGNATURE 16b.
<br />LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />F
<br />® Burial ❑ Donation
<br />Chris McCoy 1
<br />1191
<br />November 2, 2015
<br />❑ Cremation ❑ Entombment
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />❑ Removal ❑ Other (Specify)
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />17b. Zip Code
<br />68801
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH See instructions and exam les
<br />ts. PART I. Enter the chain of events --diseases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac onset, I APPROXIMATE INTERVAL
<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. I
<br />IMMEDIATE CAUSE: t onset to death
<br />IMMEDIATE CAUSE (Final a) Acute On Chronic Hypercapnic Respiratory Failure Days
<br />disease or condition resulting 1
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />Sequentially list conditions, if b) Healthcare Associated Pneumonia t Days
<br />1
<br />any, leading to the cause listed 1
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF: t onset to death
<br />Years
<br />c) Chronic Obstructive Pulmonary Disease t
<br />Enter the UNDERLYING CAUSE 1
<br />(disease or injury that initiated
<br />the events resulting in death)DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />LAST t
<br />d) 1
<br />1
<br />18. PART IL OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART
<br />1. 19. WAS MEDICAL EXAMINER
<br />Acute Renal Failure, Metabolic Acidosis, Atrial Fibrillation, Diabetes Mellitus, Cardiomyopathy,
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />W
<br />20. IF FEMALE:
<br />21a. MANNER OF DEATH
<br />21b. IF TRANSPORTATION INJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />LL
<br />H
<br />❑ Not pregnant within past year
<br />®Nature) ❑ Homicide
<br />❑Driver/Operator
<br />❑ YES ® NO
<br />U
<br />❑ Pregnant at time of death
<br />1:3 Accident ❑ Pending Investigation
<br />1:1Passenger
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Suicide ❑ Could not be determined
<br />❑ Pedestrian
<br />❑Not pregnant, but pregnant 43 days to I year before death
<br />❑ Other (SPeclly)
<br />❑ YES ❑ NO
<br />❑ Unknown N pregnant within the past year
<br />E
<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 />0
<br />v
<br />g
<br />22d. INJURY AT WORK?
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />H
<br />[]YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />239. DATE OF DEATH (Mo., Day, Yr.)
<br />z 124a.
<br />=
<br />DATE SIGNED (Mo., Day, Yr.) 124b.
<br />TIME OF DEATH
<br />S W
<br />October 29, 2015
<br />r s
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d.
<br />TIME PRONOUNCED DEAD
<br />z
<br />r
<br />=
<br />October 29, 2015
<br />06:53 AM
<br />Fa' c
<br />3d. To the beat of my knowledge, death occurred at the time, date and place
<br />TtN)
<br />240. On the basis of examination and/or investigation, In my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and This)
<br />S2
<br />W z
<br />g O
<br />G
<br />and due to the cause(s) staled. (Signature and
<br />o D
<br />~
<br />Jay C. Anderson, MD
<br />0
<br />TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />26b. WAS CONSENT GRANTED?
<br />YES ❑NO ❑PROBABLY ❑UNKNOWN ❑ YES ® NOcable
<br />LJa25.DID
<br />if 28a is NO ❑YES ❑ NO
<br />ME, TITLE AND ADDRESS Of- GFK I ype or nty
<br />C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE28b.
<br />DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 2, 2015
<br />
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