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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 OFISSUANCE
<br />4112/2019
<br />LINCOLN, NEBRASKA
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<br />202106914
<br />RUSSELL FOSLER
<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. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Keith Richard Rolls
<br />4<CITY':ANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Leroy, Nebraska
<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 />MOIL
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 2, 2019
<br />6. DATE OF BIRTH (Mo.Dayd Yr,)
<br />July 1, 1938
<br />7. SOCIAL SECURITY NUMBER
<br />508-40-1938
<br />b FACILITY -NAME (If not 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 />9a RESIDENCE$TATE
<br />Nebraska
<br />8d. STREET AND NUMBER
<br />715 W John St
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />® ER/Outpatient
<br />0 DOA
<br />9b. COUNTY
<br />Hail
<br />Sc. CITY OR TOWN
<br />Grand'island'
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />r --
<br />8d. COUNTY OF DEATH
<br />Hall
<br />0 Hospice Facility
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />2 YES ❑ NO
<br />lila. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 1_1 Widow ed 0 Divorced 0 Unknown
<br />1. FATHER'S -NAME '(First, Middle, Last, Suffix)
<br />Kenneth Rolls
<br />12, EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />( ] Burial 0 Donation
<br />0 Cremation 0 Entombment
<br />❑,Removal 0 Other($PecifY)
<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
<br />10b. NAME Of SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Gladys R Kart
<br />i'-12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />14a. INFORMANT -NAME .;
<br />Gladys Rolls
<br />Vera Mohlman
<br />16a. EMBALMER-SIGN/MIRE
<br />Stacie L Ruiz
<br />18b. LICENSE NO.
<br />1495
<br />14b. RELATIONSHIP TO DECEDENT.;.
<br />Wife
<br />16c. DATE (Mo., Day. Yr.)
<br />April 8, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Cedarview Cemetery
<br />CITY /TOWN
<br />Doniphan
<br />STATE .....
<br />Nebraska
<br />17b,.2.:RCode
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />IL PART I. Enter the Chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter Limning events such as cardiac arrest,
<br />respiratory arrest, 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 />IMMEDIATE CAUSE (Final a) Sudden Cardiac Death
<br />disease or condition resulting
<br />in death)
<br />Sequentially Nst conditions, if
<br />any, leading to the cause Bated
<br />on line a
<br />Enter the. UNDERLYING CAUSE
<br />(disease or hijury that Initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Ventricular Fibrillation
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />APPROXIMATEINIERVAL:i.
<br />onset to death
<br />Minutes
<br />onset to death
<br />Minutes
<br />onset to death
<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 />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />❑
<br />❑ Net Not pregnant, but pregnant within 42 days of death
<br />pregnant, but prlrgnent:'43 days to 1 year before death
<br />❑ tlpknewa itt?r4gnaMwithifi the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d.INJURY AT WORK?
<br />]YES ❑ NO
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />216.1P TRANSPORTATION
<br />❑ Driver/Operator
<br />❑ Passenger
<br />Pedestrian
<br />Other(spedity)
<br />INJURY
<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 PeAnts
<br />0 YES 0 NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />7J
<br />tti
<br />< 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />0
<br />'244,. DATE OF DEATH (Mo., Day, Y
<br />i
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />g U Z
<br />J Q
<br />A g 6
<br />S
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY ® UNKNOWN
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />3d. To the test of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />STATE
<br />24aa. DATE SIGNED (Mo., Day, Yr )
<br />April 5, 2019
<br />24b. TIME OF DEATH
<br />07:45 PM
<br />ZIP CODE
<br />24C. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD
<br />April 2, 2019 07:45 PM
<br />24e. On the basis of examination andlor investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />Williamette Gallagher, County Attorney
<br />26a. HAS ORGAN OR 'OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 7 •
<br />26b. WAS CONSENT GRANTED'?
<br />Not Applicable if 26a Is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Willamette Gallagher, County Attorney, 231 S Locust Street, Grand Island,.Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATURE �?? //'
<br />28b. DATE FILED BY REGISTRAR (M0,Day, Yr.)
<br />April 8, 2019
<br />
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