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E.".?fir. s II laut�s9($Ritll3tgi't $]lwcfttSIiI1Y(tfs?', tyf rat -=.YS $}3Slxtity�\\LP 4Y9t♦' llWa�*•iiTa:; Sf7,1 �lA�Fi¢ 3 ?4 -x+.re 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 10/19/2020 LINCOLN, NEBRASKA 202008480 I 2rt_it OPLAAfilibt SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 20 13815 IPursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death. I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Donald James Van Bibber 2. SEX Male 3. DATE OF DEATH (Mo:, Day, Yr.); September 29, 2020 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Grand Island, Nebraska (Yrs.) 84 MOS. DAYS HOURS MINS. April 16,1936 7. SOCIAL SECURITY NUMBER 507.36.2073 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER 0 Nursing Home/LTC A Hospice Facility 8b. FACILITY-NAME(If not Institution, give street and number) Edqewood Vista Grand Island 0 ER/Outpatient 0 Decedent's Home 0 DOA ® Other (Specify)ASSISTED LIVING 8c, CITY OR TOWN OF DEATH (Include Zip Code) 18d. Grand Island 68803 I COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 824 North Custer 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE WY LIMITS ® YEs ❑ NO 10a MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married ❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Nancy Ruth Frey 11, FATHER"aNAliME (First, Middle, Last, Suffix) Phillip Van Bibber 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Thelma McClurkin 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Nancy Ruth Van Bibber 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION I Burial : ❑ Donation 16a. EMBALMER -SIGNATURE Daniel D Naranjo 16b. LICENSE NO. 1071 16c. DATE (Mo., Day, Yr.) October 3, 2020 Cremation 0 Entombment ❑ Removal' 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Alf Faiths' Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b.zip Cods 88801 CAUSE OF DEATH (See instructions and examples) 18. PART 1. Enter the chain of events- -0le , injuries, or complications4het directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory IMMEDIATE disease or condition in death) arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Esker only one cause on a line. Add addltional lines if necessary. IMMEDIATE CAUSE: CAUSE wow -_ a) Respiratory Failure resulting onset to death 1 Day DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, it b) Dementia any, leading to the cause listed on line a. onset to death 2 Years DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or ',duty that initiated onset to death the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Chronic Obstructive Pulmonary Disease, Diabetes 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED?` ❑ YES ®NO 20. IF FEMALE: ❑` Met pregnant wlg0npaetYear 0 Prepnera at tiro of *mei 21a. MANNER OF DEATH ® Natural ❑ Homicide 0 Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES NO ❑ <Nat pregnant, but pregnant within 42 days of death ElNot pregnant, but pregnant 43 days to 1 year before death ❑.. Unknown 1 pregnant within the past year ❑Suicide ❑Could not be determined El pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO 22s. DATE OF INJURY No., 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 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22t LOCATION OF INJURY STREET a NUMBER, APT.NO. CITY/TOWN STATE ZS, CODE To be completed by. MEDICAL CERTwER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) September 29, 2020 To be completed by CORONERS PHYSICIAN m COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) October 8, 2020 23c. TIME OF DEATH 11:45 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3d. Ya the best ofmy knowledge, death occurred at the time, date and place and due to the cause(s) stated. (signature and nils) Isaac J. Berg, MD 24e. On the basis of examination and/or Inveetiga Ion, In my opinion death cecurnd K the time, data and place and due to the causes) stated. (Signature end Title)j 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES '❑ NO 0 PROBABLY ® UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO „ ❑ YES 0 No 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATUREQat Jif October 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) 16, 2020 O) O) oo