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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 />_
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECOR> t �rI ,r r �}
<br />SARAH BOHNENKAMP
<br />2 O 2 O O 9 5 2
<br />ASSISTANT
<br />REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DATE OF ISSUANCE
<br />2/4/2020
<br />LINCOLN, NEBRASKA
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Jerry Gene Dimmitt
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 23, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-42-4146
<br />5a. AGE Last Birthday
<br />(Yrs.)
<br />Sb. FACILITY -NAME Wool -institution, give street and number)
<br />7417 $ 90th Road
<br />78
<br />Sb. UNDER 1 YEAR
<br />MOS. DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />0 ER/Outpatient
<br />Q DOA
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />6. DATE OF BIRTH (Mo.. Day, Yr.)..
<br />March 30, 1941
<br />OTHER ❑ Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />0 Hospice Facility
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Wood River 68883
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9a, RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />7417 S 90th Road
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Wood River
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />9g. INSIDE CITY LIMITS
<br />❑ YES ® 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) If wife, give maiden name,
<br />Patricia Jo DeManr
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Roy Dimmitt
<br />112. MOTHERS -NAME (First, Middle, Maiden Surname)
<br />Eva Etta Rosetta Fox
<br />13. EVER IN U.S, ARMED FORCES? Give dates of service if Yea.
<br />(Yes, No, or Link.) No
<br />14a. INFORMANT -NAME
<br />Patricia Jo;Dimmi t ;.
<br />14b. RELATIONSHIP TO DECEDENT,.
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑ Bunat 0 Donation
<br />® Cremation 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />January 27, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY /TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />estate of the
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island. Nebraska
<br />17b. Z3p;Code
<br />68801
<br />CAUSE OF DEATH (See Instructions and examples)
<br />I8 PART I. Enter the chain of events- -dl , Injuries, or complications -that directly caused the death, DO NOT enter terminal events such as cardiac arrest,
<br />rwpiratary 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 />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />in death}
<br />Sequentially tat conditions, If
<br />any, leading to the cause listed
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(*seesaw- injury that Initiated
<br />the events resulting:In death)
<br />LAST
<br />a) Metastatic Adenocarcinoma
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />APPROXIMATE:INTERVAL :;
<br />onset to death
<br />2 Months
<br />onset to death
<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 />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />0 Nat 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 />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ©NO
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could hat be determined
<br />22b. TIME OF INJURY
<br />21b. If TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />pedestrian
<br />EI Other(8pecity)
<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 ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />23d. To the best of my knowledge, death occurred et the time, date and place
<br />and due to the causal') stated. (signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY ® UNKNOWN
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />January 27, 2020
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />January 24, 2020
<br />24b. TIME OF DEATH
<br />Unknown
<br />24d. TIME PRONOUNCED DEAD
<br />07:15 PM
<br />24e. On the basis of examination end/or investigation, In my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />Willamette Gallagher, County Attorney
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES ®NO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a Is NO 0 YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />WiitiametteGallagher, County Attorney, 231 S Locust Street, Grand Island, Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Vt.)
<br />January 29, 2020
<br />
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