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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 DEPOSITARY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />2/13/2020
<br />LINCOLN, NEBRASKA
<br />20210366
<br />gisStkiltkottik
<br />SARAH BOIINENKAMP
<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 />1. DECEDENTBNAME (reset, Middle, Last, Suffix)
<br />David Alan Elliott'
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Lincoln, Nebraska..
<br />5a. APE'- Last Birthday 5R. UNDER 1 YEAR
<br />(Yrs.)
<br />2. SEX
<br />Male
<br />5c. UN)ER 1 DAY
<br />MOS.
<br />73
<br />DAYS
<br />HOURS
<br />SOCIAL SECURITY. NUMBER
<br />507-564821'
<br />E
<br />e
<br />8b. FACILITY -NAME (If not institution, give street and number
<br />804 Redwood Road
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68003
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />94 STREET AND; NUMBER
<br />804; Redwood Rdaad
<br />10a. MARITAL STATUS AT TIME OF DEATH 1 Married 0 Never Married
<br />0 Marled, but separated 0 Widowed ❑ Divorced 0 Unknown
<br />MINS.
<br />20 01622
<br />3. DATE OFDEATI'I (180.,047,lr s
<br />February 8,2020
<br />6. DATE OF BIRTH (MO, Day, Yr.)
<br />December 27, 1946
<br />8a. PLACE OF DEATH
<br />HOSPITAL © Inpatient OTHER 0 Nursing Hom.ILTC
<br />ER/outpatient ® Decsdsnt's Herne
<br />0 DOA 0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />❑ Harplc, Facility
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NC.
<br />Of. ZIP CODE 90INSIDE 'C)mm LHRPTs
<br />1 68803 I MI 'en > Q NO
<br />11. FATHER'S -NAME (first, Middle, Last, Suffix)
<br />Moms Elliott
<br />10b. NAME OF SPOUSE (FIrst,
<br />Susan Weatherly
<br />Middle, Last, Suffix) if wife, give ntdderh :mane
<br />1 12. MOTHERS -NAME (First, Middle, Malden Surname)
<br />Elaine Yost
<br />13. EVER IN U.S.ARMED :FORCES? Give dates of service 11 Yes. 14a. INFORMANT -NAME
<br />_ (Yes, No, or Unk.) Yes 03/16/1966-01/15/1969 Susan Elliott
<br />15. METHOD OF DISPOSITION 16a. EMBALMER -SIGNATURE
<br />0 Burial Donstian Not Embalmed
<br />❑ tremabori 0 Entombment
<br />❑ Rommel j Other (Si b)
<br />18d. CEMETERY, CREMATORY OR OTH
<br />Nebraska Anatomical Board
<br />LOC TIO
<br />17a. FUNERAL NOME NAMe AND MAILING ADDRESS (Street, City or Town, State),;
<br />Al Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />0
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Omaha
<br />CAUSE OF DEATH tees Instructions. and examples)
<br />Is. PART L Enter the chain of events- -diseases, hrJude• or complications -that dl -e!•.? Cause.! .ennirm events such as cardiac sett,_
<br />�.
<br />IMMEDIATE CAUSE: ..
<br />. �., - rose z -.....
<br />131MEDIRTE.CAME (Kbrat a/ Metastatic Squamous Cell Cancer Of The Ureter'
<br />disease or cdndiHOn tsrWNng
<br />in deatih) DUE TO, OR ASA CONSEQUENCE OF:
<br />Sequentially list conditions, N b)
<br />any, leading** the muse lbted
<br />ver tinea DUE TO, ORAS A CONSEQUENCE OF:
<br />Maw Ss UNDERLYING CAUSE .. c)
<br />(disease m (Nary Eat initiated`
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />lSc. DATE (Mo.,, Day, Yr.)
<br />February 8, 2020
<br />the Cryan resulting in dea41) DUE TO, OR AS A CONSEQUENCE OF:
<br />tA$T d)
<br />18. PART ti.OTHER SIGNIFCCANT CONDITIONS -Conditions contrlbUdng to the deet but not re ulfing in the underlying cause given In PART I.
<br />Hypertension
<br />2 20. IF FEMALE: ,
<br />Net Pregnant Well past year
<br />0 magmata *Maewm
<br />-N . ❑ Not pregnant, Ixd4 punt vdtdn 42 days of death
<br />S. • 1 0 Not pregnant, Wd pregnant 43 days to 1 vu: before ceadt
<br />0 Unknown N pregnant *thin the put year
<br />g�g
<br />12
<br />E
<br />ei
<br />22.
<br />PATE Of INJURY No.,. Day, Yr.)
<br />21a. MANNER OF DEATH .
<br />® Natural 0 Hcmi Id.
<br />❑
<br />Accident 0 Pendln lmestigatl0n
<br />0 Suicide tJ Could not 9 t determined
<br />22b. TIME OF INJURY
<br />22d. INJURY AT WORK?
<br />❑ YES 0 N
<br />22c. PLACE OF INJURY -A1
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 8, 2020
<br />23b. DATE STONED (Mo., Day, Yr.)
<br />February 11 2020
<br />CITYJTOWN
<br />23c. TIME OF DEATH
<br />03:50 AM
<br />224. To the test of my knowledge, death occurred at the time, date and place
<br />and duo to ttia cause(s) stud. (Signature and Tide)
<br />Ryan D. Crouch, DO
<br />21b. IF TRANSPORTATION
<br />❑ drive ffiperatsa
<br />0 Pa isseer
<br />0 pedeetrien
<br />Cl Other p)deciy)
<br />INJURY
<br />APPROXIMATE INTERVAL
<br />onset to geatb
<br />18 Months
<br />onset to death
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® 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 />ome, fere, street, factory, office building, construction site, eilL(tipreify)
<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 Om Me bp*)S of examination and/or lnvestgaton, M my opIdon death ASSUfred at
<br />MAO* date and place and due to the cause(a) stated. (Signature a n4 14)
<br />25.010 TOBACCO USE CONTRIBUTE TO THE DEATH? a p/
<br />®;YE$ ❑;d/4 ❑';PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />2$b. WAS CONSENT GRANTED? <.
<br />Not Applicable If 26a is NO: Q YES'' Q NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />4 %I tLrr .ry€
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 11, 2020
<br />C.)
<br />N
<br />....... j
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