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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 />5/5/2020
<br />LINCOLN, NEBRASKA
<br />202100477
<br />'644.:1' 41.krf>9dt
<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 05608
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Jack Ray: .Briggs
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 29, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />St. Paul, Nebraska
<br />7. SOCIAL SECURITY' NUMBER
<br />506-50-1354
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (Knot Institution, give street and number)
<br />''01 !
<br />a CHI Health St. Elizabeth
<br />1
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Lincoln 68510
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />79
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRT140Mo., Day, Yr.)
<br />March 10, 1941
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Lancaster
<br />❑ Hospice Fac(fity
<br />9d. STREET AND NUMBER
<br />4005 Mason Ave
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S•NAME (First, Middle, Last, Suffix)
<br />Al Briggs
<br />13. EVER 1N U,$. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 08/02/1960-08/02/1964
<br />15. METHOD OF DISPOSITION
<br />0 Burial ❑ Donation
<br />j Cremation El Entombment
<br />0 Removal 0 Other (Specify)
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />'9g. IN$iDECITY LIMITS`
<br />® YES
<br />EyNONi
<br />1Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Betty Clifton
<br />14a. INFORMANT -NAME
<br />Betty Briggs
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12. MOTHER'S -NAME (First, Middle, Maiden Sumame)
<br />Harriette Wilson
<br />16b. LICENSE NO.
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />May 1, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY / TOWN
<br />Gibbon
<br />STATE'.
<br />Nebraska
<br />17a, FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />16. PART I. Enter the chain of events- -diseases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />reef 'rater? e.-razq .r veni,ic:aai ta.rlfa::cn without s'rnwre2 the etiology. nn MOT ACP-RFl1a1F-. Font,' only one Gauen nn = Ilne. Add additional line If necessary.
<br />11 IMMEDIATE CAUSE:
<br />laIMMEDIATE CAU$E(FinaI a/ COVI D-19 inieGion
<br />e dtsessa crconditlon resulting
<br />9
<br />In death)
<br />d
<br />at
<br />ts
<br />C
<br />0
<br />ie
<br />47
<br />to
<br />E
<br />w
<br />e
<br />a
<br />DUE TO, OR F S A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading to the cause listed
<br />on ane s.
<br />Etter the UNDERLYING CAUSE
<br />(disease or injurythat initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />17b. Zip Code
<br />68801
<br />. APPROXIMATE INTERVAL
<br />onset to death
<br />Davis
<br />onset to deaih
<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 />Hypoxic Respiratory Failure, Pneumonia
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20. IF FEMALE:
<br />0 Not pregnant within Past year
<br />�..., Pregnant et time Of death
<br />©; **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 year
<br />21a. MANNER OF DEATH
<br />El Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />22e DATE OF INJURY (Mo„ Day, Yr.)
<br />22b. TIME OF INJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES Ea NO
<br />21 d. WERE AUTOPSY FINDINGS AVArtiketE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES Q NO
<br />22e. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, ate, (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22r. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN
<br />STATE
<br />ZIP:CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)= , 24a. DATE SIGNED (Mo., Day, Yr.)
<br />L' April 29, 2020 _ __. _ � ___ B
<br />1 r 23b. DATE SIGNED (Mo., Day, Yr.) 23e. TIME OF DEATH s g k 24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />- � oMaY 1.2020 11:23 AM
<br />r0.
<br />3d. To the best of my knowledge, death occurred at the time, date and place € ug z
<br />8 end due to the cause(s) stated. (Signature and Title) lol3 8
<br />2 Sean Hansen, MD i- § li
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />Q YES l NO '❑ PROBABLY 0 UNKNOWN
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />20a. On the basis of examination and/or Investigation, In my opinion death OdCurred et
<br />the time, date and place and due to the cause(s) stated. (Signature WWI Tele)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />21. NAME, TITTLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Sean Hansen, MD, 555 South 70th Street, Lincoln, Nebraska, 68510
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable H 26a Is NO 0 'YES
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 1, 2020
<br />
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