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<br />)itr •.,,;,, , STATE OF NEBRASKA
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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 />8/31/2017
<br />LINCOLN, NF914ASKA
<br />Amended
<br />i
<br />202102423
<br />awl
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />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 />Gerald Eugene Riese
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Doiriphan, Nebraska
<br />ba. AGE Last Birthday
<br />(Yrs.)
<br />84
<br />51). UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 7, 2017
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />February 28, 1
<br />933
<br />7. SOCIAL SECURITY NUMBER
<br />508-38-1073
<br />8b. FACILITY -NAME (If not tnetitutlon, give street and number)
<br />• ("rand latent) Lakeview Cara & Rr:Piabiiitatiorl Canter
<br />cr 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />• .Grand. Island 68801
<br />9a. RESIDENCE -STATE
<br />z; Nebraska
<br />E 9d. STREET AND' NUMBER
<br />E
<br />c 2417 North Taylor Avenue
<br />w
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpetlent
<br />❑ DOA
<br />9e. CITY OR TOWN
<br />Grand Island
<br />OTHER ® Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Speclfy)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />0 Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />0 YES ❑ NO
<br />10a. MARITAL STATUS AT;T1ME OF DEATH ® Married 0 Never Married
<br />Monied, but separated Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />m John Riese
<br />E 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />8(Yes, Noor Unl.) Yes 03/09/1953-02/10/1957
<br />, 15. METHOD OF DISPOSITION
<br />H 0 Burial ❑ Donation
<br />Cremation 0 Entombment
<br />❑ Removal Q Other (.Specify)
<br />19b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name::,,
<br />Sharlene VanPelt
<br />1.12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Agnes Kolbet
<br />14a. INFORMANT -NAME
<br />Sharlene Riese
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />August 9, 2017
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITU / TOWN
<br />Central Nebraska Cremation Services I"
<br />Gibbon
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska for
<br />Central Nebraska Cremation & Mortuary Service. 609 Front Street. PO Box 280. Gibbon. Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART'i. Enter the chain of event*- diseases, Injuries, or complications -that directly caused the death. DO NOT enter temente
<br />respiratory arras), cr vete/leafier fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only Dna cause on a
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />d death)
<br />sagWntialty Ilst conditions, If
<br />my, leading to the cause lieted
<br />on line a
<br />Enter the UNDERLYING CAUSE
<br />KiSeafp pr injury that initiated
<br />the evgf is reeuttineln death)
<br />LAST
<br />a) Respiratory Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />>b) Failure To Thrive
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Depression
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />events such as cardiac arrest,
<br />line. Add additional lines a necessary.
<br />STATE
<br />Nebraska
<br />17b.ZpCode
<br />68801
<br />68840
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />2 Days
<br />onset to death >.
<br />3 Months
<br />onset to death
<br />3 Months
<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 />Light Chain Nephropathy, Diabetes Mellitus, Congestive Heart Failure
<br />tkt
<br />w . IF FEMALE:
<br />K❑ Not pregnant within pest year
<br />V0 Pregnant at time of death
<br />0 Not pregnant, but pregnant within 12 days of death
<br />Ai.❑ Not pregnern, but pregnant 43 days to 1 year before death
<br />0 unknown N pregnant within the past year
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />0
<br />V
<br />.41 22d. INJURY AT WORK?
<br />1-
<br />YES ❑ NO
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 AriverlOperater
<br />❑ Passenger
<br />0 Pedestrian
<br />Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES El 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 />ALIGUS4 7, 2017
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Au ust 8 2017
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />.9:54 PM
<br />3.
<br />'' 0 3d. To the bast of my knowledge, death occurred at the time, data and place
<br />2 S and due to the cause(s) stated. (Signature and Title)
<br />o
<br />2 Isaac J. Berg, MD
<br />26. DO TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES 1 NO 0 PROBABLY 0 UNKNOWN
<br />S
<br />�
<br />q s
<br />STATE ZIP CODE
<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 tkne, dote and place and due to the cause(*) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 0 NO
<br />26b. WAS CONSENT GRANTED?:
<br />Not Applicable if 26a is NO 0 YES ©NO'
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S MONATURE
<br />Amended
<br />8/3112017 Item 7 Sodi01 Security Number
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 9, 2017
<br />
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