|
• Si
<br />311%1' i( aS4t'".•'4 ,li
<br />Noloth
<br />(tt#tdrarltl. 1tiaata#t.t.y,))'t1)ra;it.$�t$t!iIt?r<atrs�t3£I$i;V',9tS1Eb(
<br />��f�rtzaaaShWwzzw� . �&99t�1'N�t�3p �gr•,aayA�tA��?<^�"�H
<br />1111
<br />$liul•
<br />Seta : t,raaaaanr��t t,
<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 />"'202008 i 98
<br />RUSSELL FOSLER DEPARTMENT HEALTH AND
<br />DATE OF ISSUANCE
<br />8/16/2018
<br />LINCOLN, NEBRASKA
<br />INTERIM ASSISTANT STATE REGISTRAR HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Earl Eugene Speer
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 6, 2018
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Bayard, Nebraska
<br />5a. AGE;- Last Birthday
<br />(Yrs.)
<br />93
<br />Sb. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />8. DATE OF BI
<br />TH IM tr„ Day, Yr.).
<br />August 8, 1924
<br />7. SOCIAL SECURITY NUMBER
<br />505-20-6978
<br />Sb. FACILITY -NAME (If not Institution, give street and number)
<br />Park Place -A Golden Living Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />Ba. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />223 S Oak St.
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Edgar Leroy Speer
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ERlOutpatient
<br />© DOA
<br />8c. CITY OR TOWN
<br />Grand Island
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />0 Hospice Facility
<br />90INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Dema Speer
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Wilhelmina Teckla Meidlinger
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Urfk.) Yes : 01/29/1944-05/17/1946
<br />14a. INFORMANT -NAME
<br />Dema Speer
<br />14b. RELATIONSHIP TO DECEDENT.
<br />Wife
<br />'O
<br />d
<br />.t.
<br />a
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />Cremation 0 Entombment
<br />❑ Removal [] Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />Bq. LICENSE NO.
<br />16c. DATE (Mo:, Day, Yr.);
<br />August 7, 2018
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Crematory
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Livinaston-Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska
<br />Grand Island
<br />CAUSE OF DEATH (Seejnstructions and examples)
<br />1e. PART I. Enter the cha,n 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 lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a)Aspiration Pneumonia
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />M death)
<br />Sequentially list conditions, If
<br />any. leading to the cause listed.
<br />on line a
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury Mat Initiated
<br />the events resulting In death)
<br />LAST
<br />STATE
<br />Nebraska
<br />tib. Zip Code
<br />68803
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Hiatal Hernia
<br />onset to death>
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />Malnutrition, Acute Kidney Injury, Dehydration, Atrial Fibrillation, Hypertension, COPD
<br />• ,20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />0 Not pregnant, hut pregnant within 42 days of death
<br />❑ Not pregnent, but pregnant:, 43 days to 1 year before death
<br />0 Unknown If pregnant within the past year
<br />r
<br />Y
<br />0
<br />w
<br />v
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />g22d, INJURY AT WORK?
<br />.o ❑ YEs ❑ NO
<br />• 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />O
<br />21a. MANNER OF DEATH
<br />Ea Natural 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />❑ Suicide 0 Could not be detennined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO,
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ iNO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />CITY/TOWN
<br />STATE ZIP CODE
<br />PI 23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 6, 2018
<br />• 423b. PATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />• u 23d. Tougust 6, 2018 3:OOAM
<br />the best of my�
<br />knowledge, death occurred at the d place
<br />ttl • B i and due to the cause(s) stated. (Signature and Title)
<br />e ' 1 Jay C. Anderson, MD
<br />a.
<br />125. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY ® UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803,
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<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 causes) stated. (Signature and Tale)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />28a. REGISTRAR'S
<br />SIGNATURE yam'
<br />26b. WAS CONSENT GRANTED/
<br />Not Applicable if 26a Is NO 0 YES Q NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day,. Yr,)
<br />August 13, 2018
<br />CO
<br />(A)
<br />
|