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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 />3/16/2021
<br />LINCOLN, NEBRASKA
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<br />20210690►
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />'11111101!4 y 11r551146;4313,,fLi ,(114 ..t�
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Gerald Walter Lothrop
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Brush, Colorado
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />80
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />21 03364
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />March 10+ 2021
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />June 16,:.;1940
<br />7. SOCIAL SECURITYNUMBER
<br />506-50.9579
<br />8b. FACILITY -NAME (if not Institution, give street and number)
<br />18551 W Husker Highway
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Shelton 68876
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Shelton
<br />OTHER ❑ Nursing Home/LTC
<br />E Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Hobpice FaciliCy
<br />9d. STREET AND NUMBER
<br />18551 W Husker Highway
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68876
<br />9g. i 4SIDE CtT
<br />❑ YES
<br />Y LIMITS
<br />E NO
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Mary King
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Edward Lothrop
<br />13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />1 13, MOTHER'S -NAME (First,
<br />Agnes Madsen
<br />14a. INFORMANT -NAME
<br />Mary Lothrop
<br />Middle, Maiden Surname). '>
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />Burial 0 Donation
<br />E Cremation 0 Entombment
<br />Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />16b. LICENSE NO.
<br />CITY I TOWN
<br />Gibbon
<br />16c. DATE (Mo., Day, Yr.)
<br />March 11, 2021
<br />STATE
<br />Nebraska
<br />17a, FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />AD -fel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. 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 lino. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Chronic Respiratory Failure
<br />IMMEDIATE CAUSE (Final
<br />dtaease or condition resulting
<br />in death)
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury that initiated
<br />the events resulting in death)
<br />LAST
<br />18.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Chronic Obstructive Pulmonary Disease
<br />17b. Zip Code
<br />66801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />5 Years
<br />onset to death
<br />Chronic
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />Pregnant at 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 />228 DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />OYES El NO
<br />21a. MANNER OF DEATH
<br />ENatural 0 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 />0 Pedestrian
<br />❑ other (Specify)
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONERCONTACTED?
<br />❑ YES 1 NO
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />21d. WERE AUTOPSY; FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, eta (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22t. LOCATION! OF INJURY STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 10, 2021
<br />g $ F 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />u gMarch 11. 2021 05:14 PM
<br />d. To' the beat of my knowledge, death occurred at the time, date and place
<br />SI 8 and due !tithe ousels) stated. (Signature and Thkr)
<br />E ~ 2 Ryan D Crouch, DO
<br />0.
<br />STATE ZIP CODE'7.
<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 />24s. On the basis of examination and/or inveatige en, in my opinion death tgcurrid at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)::
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES 0 NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES (]NO
<br />28b. WAS CONSENT GRANTED?..
<br />Not Applicable if 26a is NO DYES f.:1
<br />NO
<br />2?, NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan 0 Crouch, DO, 800 N Alpha St, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 15, 2021
<br />i
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