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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OFfiiaAL + CERTIFIES
<br />THE BELOW TO BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH`iiE lye
<br />.A ?4 ;� ` „ •, y4AD
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITc R . pt, 4/ff41
<br />DATE OF ISSUANCE
<br />02/18/2011
<br />20200697
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<br />LINCOLN, NEBRASKA ' fM�l1f; 1�1J�.•
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER+
<br />CERTIFICATE OF DEATH
<br />To be completed/verified by: FUNERAL DIRECTOR I
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Gene Frank Van Cleave
<br />2. SEX
<br />Male
<br />.,S,DATE.OR,D(:ATffQto;IDay,Yr:)
<br />Fe' brttar)r 15'4', 2611 i. "
<br />-
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />51). UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />S. DATE OF BIRTH (Mo., Day, Yr.)
<br />Grand Island, Nebraska
<br />(Yrs.)
<br />83
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />November 28, 1927
<br />7. SOCIAL SECURITY NUMBER
<br />508-18-7251
<br />Ba. PLACE OF DEATH
<br />MEM ® Inpatlent OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />Sb. FACILITY -NAME (If not Institution, give street and number)
<br />Saint Francis Medical Center
<br />0 ERIOulpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />Sc. CITY OR TOWN OF DEATH (include Zip Code)
<br />Grand Island 68803
<br />ed. COUNTY OF DEATH
<br />Hall
<br />Gla. RESIDENCE -STATE
<br />Nebraska
<br />Ob. COUNTY
<br />Hall
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />sd. STREET AND NUMBER
<br />1009 Oak St.
<br />'Se. APT. NO.
<br />Of. ZIP CODE
<br />68801
<br />99. INSIDE CITY UNITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) N wife, give maiden name
<br />Mabel Duering
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />William Dallis Van Cleave
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Bessie Ella Dobberstein
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or link.) Yes 06/07/1945-08/10/1951
<br />14a. INFORMANT -NAME
<br />Mable Van Cleave
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16e. DATE (Mo., Day, Yr.)
<br />February 16, 2011
<br />® Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See Instructions and examples)
<br />To be completed by: CERTIFIER
<br />tae PART I. Enter the ghat of events -climates, injuries, or complications - that directly caused the death. DO NOT enter terminal wants such as cardiac arrest,
<br />respiratory west, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a One. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Hypotension
<br />disease or condition resulting
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />3 Days
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b) Colitis Due To Clostridium Difficile
<br />any, leading to the cause listed
<br />onset to death
<br />4 Days
<br />on linea. DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />(disease or injury that initiated
<br />onset to death
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underyIng cause given In PART L
<br />Renal Failure, Respiratory Failure
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />ElPregnant at tine of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />❑YES ®NO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past yea
<br />❑ Suicide ❑ Could not be determined
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES 0 NO
<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 />22d. INJURY AT WORK?
<br />❑YES ❑NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY • STREET & NUMBER APT.NO. CITY/TOWN STATE ZIP CODE
<br />B
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 15, 2011
<br />B
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />February 16, 2011
<br />23c. TIME OF DEATH
<br />01:43 PM
<br />k
<br /><
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />-1
<br />W To the best of my knowledge, death occurred at the time, dab and place
<br />E and due to the mussel stated. (Signature and Title)
<br />David R. Golan, MD
<br />E
<br />~ 6
<br />2M. On the basis of examination ander investigation, in my opinion death occurred at
<br />the time, date placeand and dueto the cause(s) stated. (Signature and TSte)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? I26a. HAS ORGAN OR TISSUE
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN I 0 YES
<br />DONATION BEEN CONSIDERED?
<br />® NO
<br />26b, WAS CONSENT GRANTED?
<br />Not Applicable If 214 Is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, HYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY A
<br />David R. Colan, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />ORNEY) (Type or Print)
<br />28a. REGISTRAR'S SIGNATURE {
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 17, 2011
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