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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 />1/27/2021
<br />LINCOLN, NEBRASKA
<br />2021.01895
<br />ASSISTANT STOAHTE REGISTRAR
<br />SAHDEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />:1. DECEDENT.S•NAME (f=irst, Middle, Last, Suffix)
<br />Garold Ray Beck
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ainsworth, .Nebraska
<br />7. SOCIAL SECURITY;NUMBER
<br />508-66-2480
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />3
<br />6i
<br />iii
<br />A
<br />E
<br />a
<br />_ts
<br />8b. FACILITY -NAME Of not Institution, give street and number)
<br />1603 Bass Rd,
<br />8cCITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand lsland 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />69
<br />613, UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />/Or ,ntiadeei
<br />21 00715
<br />3. DATE OF DEATH (Mo.,:i
<br />January 20,202t.••
<br />6. DATE OF BIRTH (Mo., D8
<br />yr:)
<br />August 14., 1951
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />0 Hospice Facility
<br />9d. STREET AND NUMBER
<br />1603 Bass Rd
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />IN$tDE C(TY LIMITS
<br />®.YES ❑NO"
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix)18 wife, give maiden name
<br />Joyce Ubben
<br />11. FATHER'S -HAMS (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First,
<br />Harold Beek Gertrude Hickman
<br />Middle, Maiden Surname)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) No
<br />14a. INFORMANT -NAME
<br />Joyce Beck
<br />14b. RELATIONSHIP TO DECEDENT;'
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />[]''Burial 0 Donation
<br />Cremattoft: ❑Entombment
<br />0 Removal ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.),
<br />January 22, 20211.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Colonial Chapel Cremation Center Lincoln
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Livindston.Sandermann Funeral Home, 601 N. Webb Road, Grand Isla
<br />nd, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART 1. Enter the chain 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) Respiratory Arrest
<br />IMMEDIATE CAUSE (Fhfai
<br />disease ar condition reauabla.
<br />in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />sequentially list conditions, H b)Asplration Pneumonia
<br />any, leading to the causelisted
<br />on 1100 a,
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />EMaitheuNDERLYINGcAUSE c) Heart Failure
<br />(disease or injurylhat initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />d)
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting' in the underlying cause given in PART I.
<br />Multiple ScJer:.osis, Prostate Cancer, Chronic Kidney Disease
<br />17b. Zip Code
<br />68803
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />15 Minutes
<br />onset to death
<br />One Day
<br />onset:to death
<br />2 Daya
<br />onset to death
<br />19. WAS MED€CAL'EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20. IF FEMALE:
<br />❑ Not pregnant Within past year
<br />Pregnant 01 time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown If pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural 0 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 />0 YES ®. NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES ❑. NO
<br />22a.:DATE OF IN3URY (Mo, Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site,
<br />.(Specify)
<br />22ct INJURY AT WORK?
<br />DYES ONO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22t, LOCATION OF €NJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 20, 2021
<br />CITYITOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 20, 2021
<br />23c. TIME OF DEATH
<br />12:30 AM
<br />25d. To die beat of my knowledge, death occurred at the time, date and place
<br />• and'. dun to the oausels) stated. (Signature and Title)
<br />Timothy J. Sullivan, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY ® UNKNOWN
<br />STATE 7JP;CODE ;.
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH`
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />240.On the basis of examination and/or investigation, in my opinion debt rxuurred at
<br />the time, date and place and due to the cause(s) stated. (Signatureaad7tae)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES ®NO
<br />26b. WAS CONSENT GRANTED? .,
<br />Not Applicable If 26a is NO ❑ YES
<br />❑ NO
<br />27,:NAME, TITLEANO ADDRESS OF CERTIFIER (Type or Print
<br />tiMothy J Su#liven, MD, 1336 West A St Suite A, Lincoln, Nebraska, 68522
<br />28a. REGISTRAR'S SIGNATURE
<br />61L -4r2.-1 / �it lrkiz rvt
<br />2Bb. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />January 21, 2021
<br />CO
<br />..J
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