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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 />12/4/2020
<br />LINCOLN, NEBRASKA
<br />20200975g
<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 />20 16734
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<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />James L Greer
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo.,,Day, Yr.)
<br />November 24, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Mitchell, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />89
<br />5b. UNDER 1 YEAR
<br />6c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />May 12, 1931
<br />7. SOCIAL SECURITY NUMBER
<br />506.28.4598
<br />8b. FACILITY -NAME (If°not Institution, give street and number)
<br />637 MacArthur Ave
<br />8e. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />Se. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />o ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />led. COUNTY OF DEATH
<br />Hall
<br />esptce Facility
<br />9d. STREET AND NUMBER
<br />637 MacArthur Ave
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />{ YES 0 NO
<br />10a.;:MARITAL STATUSATTIME OF DEATH El 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 />Rosalie B Olson
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Roy Greer
<br />12. MOTHER'S -NAME (First,
<br />Eva Spraker
<br />Middle, Maiden Surname)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 1952-1954
<br />14a. INFORMANT -NAME
<br />Rosalie B Greer
<br />14b. RELATI
<br />Spouse
<br />SHIP TO DECEDEi
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />Cremation Li Entombment
<br />❑'Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16e. DATE (Mo., Day, Yr.)
<br />November 30, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Crematory Grand Island
<br />STA'T'E.
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />l ivinpstOn-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />17b. Zip Code
<br />68803.
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART I. Enter the chain of events- diseases, injuries, or complicetions4hat 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 />IMMEDIATECAUSE (Final a) COVID-19 Infection
<br />diaoase Or condition rekultin9
<br />indeath)
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />on fine a
<br />Enter the. UNDERLYING. 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)
<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 />Days
<br />onset to death
<br />onset to death
<br />18. PARTS. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />Hypertension
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES El NO
<br />20. IF FEMALE:
<br />© Not pregnant within past year
<br />Pregnant at lineal' death
<br />❑:.:Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑Unknown H. pregnant within the past year
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES 511 NO
<br />21d. WERE AUTOPSY FINDINGS AYAiLAIN;E
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ 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 />221, LOCATION; OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN
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<br />23a.OM OF DEATH (Mo., Day, Yr.)
<br />November 24, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />November 24, 2020
<br />23c. TIME OF DEATH
<br />07:39 AM
<br />it Tothe boot of My knowledge, death occurred at the time, date and piece
<br />Arid due to the-tause(s) stated. (Signature and Title)
<br />Chad Vieth, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES Vj NO 0 PROBABLY 0 UNKNOWN
<br />U
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP CODE
<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 =tumid at
<br />the time, date and place end due to the causes) stated. (Signature end Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES El NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑ YES
<br />©NO'
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />jai►
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 1, 2020
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