|
�'Q7dF.till,Xt�/SiBlcifta.�tlltslAmem1R(A66(11114111ICni<.f aaAau uo,
<br />is
<br />�r
<br />1
<br />2tGll'tKYitltuwa ,nnrnnr, t n1 r -
<br />yn, i �: SF�i��rli1�''iiS�) rflWiit9li))jl),i//((1�il,(�,iPrh!r,11N'
<br />M1u nfilS(I ni N�?•)>1�))ii�tt••Aiidi(c(�'�rr'r sl/!
<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 de
<br />DATE OF RUSSELL FOSLER
<br />3/21/2019 ISSUANCE 2O O ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA DEPARTMENT OF HEALTH
<br />AND 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 />Garry Dean Thomas
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kearney, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506-46-0881
<br />5
<br />AGE -Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Wedgewood Care Center
<br />db. UNOER1 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 />❑ ER/OutpatieM
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />March 2, 2019
<br />8. DATE OF BIRTH (Moi Day, Yr.)
<br />August 27, 1940
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />0 Hospice Facility
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9s. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />18695 W. Rainforth Rd
<br />9b. COUNTY
<br />Hall
<br />8d. COUNT/ OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Wood River
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />9g. INSIDE CITY UMIT9 '
<br />❑ YES ® NO
<br />mm. MARITAL STATUSAT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separate.d 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Belva Thomas
<br />tob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Beverly Bormood
<br />12. MOTHER'S -NAME (First, Middle,
<br />Ilah Marie Maurer
<br />Maiden Surname)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or unit.) Yes < 01/24/1961-01/22/1965
<br />15. METHOD OF DISPOSITION
<br />❑Burial ❑ Donation
<br />® Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />14a. INFORMANT -NAME
<br />Beverly Thomas
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18b. LICENSE NO.
<br />14b. RELATIONSHI P TO DECEDENT:
<br />Spouse
<br />18c. DATE (Mo., Day, Yr.}
<br />March 5, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Aofel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />CITY / TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17b Zip code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Emyr the. Shakier events. diseases, injuries, or complications -that directly caused the death. 00 NOT *Mar tenhidal events such as cardiac arrest,
<br />respiratory sweet, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause On a line. Add additional lines it necessary.
<br />IMMEDIATE CAUSE:
<br />a) Cardiopulmonary Arrest
<br />E IMMEDIATE CAUSE (Final
<br />e disease or condition resulting
<br />id death)
<br />Sequentially list conditions, if
<br />any, leading 10 the cause tisted
<br />on linea
<br />4'
<br />B Enter the UNDERLYING CAUSE
<br />t (disease or injury that initiated:
<br />Abetment' resulting in death)
<br />LAST
<br />N
<br />d
<br />1
<br />1
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Frontotemporal Dementia
<br />APPROXIMATE INTERVAL,
<br />onset to death
<br />Immediate
<br />onset to death
<br />>5 Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Tobacco Use
<br />onset to death
<br />>40 Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset Bilotti,
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant N time of death
<br />❑ Nat pregnant, kat pregnant. within 42 days of death
<br />n
<br />0 Not ptegatrt, bad pregnant 43 days to 1 year before death
<br />0
<br />Unknown it pregnant within the past year
<br />,0 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />v
<br />s:C
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be detemNned
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 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 ❑ NQ
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />❑YES 0 N
<br />v 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />N
<br />CITY/TOWN
<br />23e, DATE OF DEATH (Mo., Day, Yr.)
<br />March 2, 2019
<br />t s 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />to Ea` e,Z March 5. 2019 07:09 PM
<br />5Qg O 3d. To the best of my knowledge, death occurred at the time, date and place
<br />3 ri a anddue to the cause(s) stated. (Signature and Title)
<br />1n '
<br />Kenneth Vettel, MD
<br />•
<br />25. DtD TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES 0 NO 0 PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Kenneth Vettel, MD, 2116 W Faidley #400, Box 9802, Grand 'stand, Nebraska, 68803
<br />28a. HAS ORGAN
<br />0 YES
<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 />240. On the basis of examination and/or investigation, In my opinion death occurred at
<br />the time, date and place and due to the cau e(s) stated. (Signature and Title)
<br />OR DONATION BEEN CONSIDERED?
<br />a NO
<br />26b. WAS CONSENT GRANTED? '
<br />Not Applicable if 26a is NO ❑ YES 0 NO
<br />28a, REGISTRAR'S SEGNATURE
<br />28b. DATE FILED BY REGISTRAR (Me., Day, Yr.)
<br />March 12, 2019
<br />
|