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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 OP ISSUANCE
<br />12/12/2016
<br />LINCOLN, NEBRASKA
<br />202103014
<br />aviti
<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 />w
<br />G
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Alan Leroy Gruwell
<br />A CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Alma, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507-74-7301
<br />5a. AGE - Last Birthday
<br />(Yre,)
<br />Sb FACILITY -NAME (If riot Institution, give street and number)
<br />CHI Health St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9e. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />62
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ERNOutpatient
<br />❑ DOA
<br />Sc. CITY OR TOWN.
<br />Grand Island'
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Y.)
<br />November25, 2016
<br />6. DATE OF BIRTH (M
<br />March 9, 1954
<br />OTHER ❑ Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9d. STREET AND NUMBER
<br />2016 Rainbow Road
<br />1Oa. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ; 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First,
<br />Herbert Gruwell
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />Day, Yt.)
<br />0 Hospice Facility
<br />9g. INSIDE CITY.LIMIT3
<br />® YES ❑ NO
<br />lob. NAME OF SPOUSE(First, Middle, Last, Suffix) if wife, give maiden name,,
<br />Rebecca Koch
<br />Middle, Last, Suffix) 12. MO'THER'S -NAME (First, Middle,
<br />Betty Gates
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, N0, or Unk.) NO
<br />15. METHOD OF DISPOSITION
<br />® Bu Tat 0 Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />14a. INFORMANT -NAME.
<br />Rebecca Gruwell
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCoy
<br />16b. LICENSE NO.
<br />1191
<br />Maiden Surname)
<br />14b. RELATIONSHIP TO DECEDENT.
<br />Spouse
<br />16c. DATE (Mo., Oar, Yr.)
<br />November 30, 2016
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)''
<br />Apfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />18, PARY L Ender theahain td events --diseases, injuries, or complications -that directly caused the death,DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arieat, of ventritiular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only One cause on a line. Add additional lines it necessary.
<br />IMMEDIATE CAUSE:
<br />Pulseless Electrical Activity
<br />IMMEDIATE CAUSE (Final a
<br />disease or condition resulting
<br />.:.in death)
<br />Segoedtially tun cuntlkiona, N
<br />any, leading to the cause tilted
<br />on line a
<br />Enter the UNDERLYING CAUSE
<br />tdiseeee or injury that Initiated..
<br />the events resulting itt (ead1
<br />` ... _. J.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Thoracic Aneurysm - Probable
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />STATE
<br />Nebraska
<br />17b, XIpCode
<br />68801 •
<br />APPROXIMATEINTERVAL:.
<br />onset to death
<br />Minutes
<br />onset to
<br />Years
<br />onset to death
<br />onset
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Hypertension, Acute Confusion, Metabolic Acidosis With Increased Lactic Acid, Bronchiectasis, Alcohol Use, Obstructive Sleep
<br />Apnea
<br />20. IF FEMALE:
<br />❑ Not pregnant within pest year
<br />❑ Pregnant at time of 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 if pregnant:within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />d..INJURY ATWORK?
<br />❑YES ONO.
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b.IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />0 Other. (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES '0440
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES [3 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 />November 25, 2016
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 6, 2016
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />04:10 AM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the consent) stated. (Signature and Title)
<br />Kimberly A. Mickels, MD
<br />25. DID TOBACCO USECONTRIBUTE TO THE DEATH?
<br />❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN
<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
<br />24e. On the basis of examination and/or investiga Ion, In my opinion death occurred at
<br />the time, date and place and due to the causes) stated. (Signature and Title)
<br />26a. HAS ORGAN OR DONAllON BEEN CONSIDERED?
<br />❑ YES al NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Kimberly A, Mickels, MD, 729 North Custer Avenue, Grand Island Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR(Mo <Day, Yr.)
<br />December 7, 2016
<br />
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