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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 />DATE OF ISSUANCE
<br />7/7/2020
<br />LINCOLN, NEBRASKA
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<br />SARAH BOHNENKAMP
<br />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 />1. DECEDENT'S -NAME ;(First, Middle, Last, Suffix)
<br />Eugene F Decker
<br />20 08621
<br />4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Lone Rock, Iowa
<br />2. SEX
<br />Male
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />70
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo.,
<br />June 23, 2020
<br />ay, Yr.)
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />7. SOCIAL SECURITY NUMBER
<br />482-60-8921
<br />8bis FACILITY -NAME (if not Institution, give street and number)
<br />2424 N. Sherman Blvd
<br />8c. CITY OR TOWN OF DEATH (include Zip Code)
<br />Grand Island 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />Sa'PLACE OF DEATH
<br />HOSPITAL Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />August 31 1949
<br />OTHER ❑ Nursing Home/LTC © Hospice Facility
<br />Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9d.;STREET AND NUMBER
<br />2424 N. Sherman' Blvd
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY umirs
<br />®'YES ❑;NO
<br />10a. MARITAL; STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name
<br />Susan Gamble
<br />11. FATHER'S -NAME {First, Middle, Last, Suffix)
<br />Clinton Decker
<br />I12. MOTHER'S -NAME (First,
<br />Stella Gordon
<br />Middle, Maiden Surname)
<br />13. EVER IN U,S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk,) Yes 01/09/1969-03/17/1976
<br />14a. INFORMANT -NAME
<br />Susan Decker
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ° Donation
<br />El Cremation ❑ Entombment
<br />0 Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />14b. RELATIONSHIP TO DECEDENT:
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />June 24, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />crrY / TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Reynolds -Love Funeral Home, 106 West 8th St, Lexington, Nebraska
<br />17b. Zip Code
<br />68850
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. 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,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Tines if necessary.
<br />IMMEDIATE CAUSE:
<br />IeMi1EDIATEcAUse (tine) a) Hemorrhagic Stroke
<br />dieeese or condition resultant
<br />in deettg
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />on Ft+e a.
<br />ander the UNDERLY1810 CAUSE
<br />(disease or injury that initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Closed Head Injury
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />19 Days
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Fall
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onaet to death
<br />18„. PART OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Cerebrovascular Disease, Adenocarcinoma Of Lung Deep Vein Thrombosis, Prostate Cancer, Obstructive Sleep Apnea
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past; year
<br />❑ Pregnant* time of death
<br />0 Not pregnant but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />21a. MANNER QF DEATH
<br />0 Natural 0 Homicide
<br />El Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />2113, IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />❑' Pedestrian
<br />0 Other(Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES El 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 />June 3, 2020
<br />22d. INJURY AT WORK?
<br />OYES ®NO
<br />22b. TIME OF INJURY
<br />02:00 AM
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site,dtc. (Specify)
<br />Home
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />Fell In Bathroom
<br />22f; LOCATIONOF INJURY: STREET & NUMBER, APT.NO.
<br />2424 N ShannonBlvd, Grand Island
<br />z
<br />0
<br />23e. DATE OF DEATH (Mo., Day, Yr.)
<br />June 23, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />4uly 6,T30
<br />3d To the beet of my knowledge, death occurred at the time, date and place
<br />Old due to the cause(s) stated. (Signature and Title)
<br />Adam Brosz, MD
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />03:23 AM
<br />a
<br />STATE
<br />Nebraska
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP CODE
<br />68803
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e.:On the basis of examination and/or investigation, in my opinion death Ofturred at
<br />thetime, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ❑ NO '❑ PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES El NO
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Adam Brosz, MD 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES
<br />❑NO
<br />28a. REGISTRAR'S SIGNATURE
<br />Ok-442.,16 �a ri Err �y
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />July 6, 2020
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