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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 CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA RczRAR`TA4Ettr OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR V041 RE S a `
<br />DATE OF ISSUANCE
<br />202005184
<br />C
<br />STANLEY S. COPPER --I,
<br />11 /06/2015202005185 ASSISTANT ST TE REGI$.
<br />DEPARTM F j4%TPI'AND
<br />LINCOLN, NEBRASKA HUNIIV
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES..' • '� -1506344
<br />' • , •Y•. ; r �
<br />CERTIFICATE OF DEATH -.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />2. SEX 3:
<br />DATE OF-DEAT o., Day, Yr.)
<br />Donald Lee Pontious
<br />Male
<br />October 29'"2015
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Sa. AGE - Last Birthday Ob.
<br />UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />DAYS
<br />HOURS
<br />MINS. '
<br />(Yrs.)
<br />Loretto, Nebraska
<br />79
<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 />K
<br />CHI Health St. Francis
<br />❑DOA ❑Other (Specify)
<br />W
<br />8c. CITY OR TOWN OF DEATH (include Zip Code)
<br />8d. COUNTY OF DEATH
<br />,
<br />a
<br />c
<br />Grand Island 68803
<br />Hall
<br />9a. RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY OR TOWN
<br />w
<br />Nebraska
<br />Hall
<br />Grand Island
<br />7
<br />9d. STREET AND NUMBER
<br />e. APT. NO.
<br />9f. ZIP CODE
<br />9g. INSIDE CITY LIMITS
<br />U.
<br />124 N. North Road
<br />68802
<br />[A 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 />ar
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />George D Pontious
<br />Fern M Giersdorf
<br />d
<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 />(Yes, No, or unk.) No
<br />Barbara Mae Pontious
<br />Spouse
<br />.S
<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
<br />1191
<br />November 2, 2015
<br />❑ Cremation ❑ Entombment
<br />16d CEMETERY, CREMATORY OR OTHER LOCATION CITY / 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 />CAUSEEA(See instructions and examples)
<br />If. PART I. Enter the chain of events --diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, 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. r
<br />IMMEDIATE CAUSE: i onset to death
<br />IMMEDIATE CAUSE (Final a) Acute On Chronic Hypercapnic Respiratory Failure Days
<br />disease or condition resulting r
<br />In deathsonset to death
<br />DUE TO, OR AS A CONSEQUENCE OF: r
<br />Sequentially list conditions, It b) Healthcare Associated Pneumonia Days
<br />any, leading to the cause listed 1
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF: r onset to death
<br />Years
<br />c) Chronic Obstructive Pulmonary Disease I
<br />Enter the UNDERLYING CAUSE r
<br />(disease or injury that initiated
<br />the events resulting in death)DUE TO, OR AS A CONSEQUENCE OF: r onset to death
<br />r
<br />LAST
<br />d) i
<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 />I. 19. WAS MEDICAL EXAMINER
<br />Acute Renal Failure, Metabolic Acidosis, Atrial Fibrillation, Diabetes Mellitus, Cardiomyopathy,
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />K
<br />W
<br />20. 1F FEMALE:
<br />21 a. MANNER OF DEATH
<br />21b. IF TRANSPORTATION INJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />H
<br />❑ Not pregnant within past year
<br />® Natural ❑ Homicide
<br />❑ DriverlOperotor
<br />❑ YES ® NO
<br />W
<br />V
<br />❑ Pregnant at time of death
<br />11 Accident Pending Investigation
<br />Passenger
<br />❑ Pedestrian
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />13 Not pregnant, but pregnant within 42 days of death
<br />11 Suicide ❑ could not be determined
<br />TO COMPLETE CAUSE OF DEATH?
<br />Not pregnant, but pregnant 43 days to 1 year before death
<br />Other (Specify)
<br />❑ NO
<br />710YES
<br />❑ Unknown if pregnant within the past year
<br />a
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />E
<br />0
<br />v
<br />T.
<br />22d. INJURY AT WORK?
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />[]YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23s. DATE OF DEATH (Mo., Day, Yr.)
<br />= w
<br />24a. DATE SIGNED (Mo., Day, Yr.) 124b.TIME
<br />OF DEATH
<br />o October 29, 2015Sa
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d.
<br />TIME PRONOUNCED DEAD
<br />F 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />J � Y
<br />''w` � October 29, 2015 06:53 AM
<br />Fe u z
<br />c
<br />24e. 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 Tide(
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />u w z
<br />g
<br />g c and due to the cousels) stated. (Signature and Title)
<br />u
<br />Jay C. Anderson, MD
<br />0
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />26b. WAS CONSENT GRANTED?
<br />® YES ❑ NO ❑ PROBABLY 11 UNKNOWN ❑ YES ® NO
<br />Nat Applicable If 26a Is NO ❑ YES ❑ NO
<br />27. NAME. TITLE AND q(Type orPrint)
<br />Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />285. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />28a. REGISTRAR'S SIGNATURE
<br />AC
<br />November 2, 2015
<br />
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