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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. f611Z01 DATE OF ISSUANCE 05/08/2013 202107189 STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND LINCOLN, NEBRASKA HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 13 01614 To be completed/willed by: FUNERAL DIRECTOR 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Richard John Payne 2. SEX Male 3. DATE OF DEATH (Mo, Day, Yr.) April 10, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 6a. AGE - Last Birthday Sb. UNDER 1 YEAR 6c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Ericson, Nebraska (Yrs.) 77 MOS. DAYS HOURS MINS. April 18, 1935 7. SOCIAL SECURITY NUMBER ea. PLACE OF DEATH Inpatient 0 Nursing Home/LTC Hospice Facility 507-44-1084 MEM& ❑ gIHER 0 8b. FACILITY -NAME (If not institution, give street and number) 5430 W. 1R Road 0 ER/Outpatient IE Decedent's Home ❑ DOA ❑ Other (specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hail ga. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 5430 W. 1R Road 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS 0 YES ® NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married 0 Maned, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF Irene Thomas SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name 11. FATHER'S -NAME (First, Middle, Last, Suffix) Gerald Payne 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Julia Sanford 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or unit.) Yes 07/31/1957-09/17/1957 14a. INFORMANT -NAME Irene Payne 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial 0 Donation 16a. EMBALMER -SIGNATURE Not Embalmed 1$b. UCENSE NO. 16x. DATE (Mo., Day, Yr.) April 11, 2013 ® Cremation 0 Entombment ❑ Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Sib) Curran Funeral Chapel, 3005 S. Locust St, Grand Island, Nebraska 17b. Zip Code 68801 1 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 10. PART I. Enter tin me) of events --diseases, Injuries, or conpliaaonaihat directly caused the death. DO NOT enter terminal events such as cardiac amaat, APPROXIMATE INTERVAL fibrillation DO NOT ABBREVIATE. Enter line. Add lines If respiratory arrest, or ventricular without showing the etiology. Only One Cause on a additional necessity. IMMEDIATE CAUSE: IMMEDIATE CAUSE (NW a) Respiratory Failure disease or condition resulting onset to death 3 Days in death] DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) Metastatic Esophageal Adenocarcinoma To Brain any, leading to the cause listed line 1 onset to death 1 6 Weeks I on a DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or Injury that Initialed Onset to death the events molting in death) DUE TO, OR ASA CONSEQUENCE OF: LAST d) onset to death 18. PART II. OTHER SIGNIFICANT CONDmONS-Condllons contributing to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? 0 YES ® NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death 21a. MANNER OF DEATH El Natural 0 Homicide 0 Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY 0 DdwIOperatw 0 Pyr 21c. WAS AN AUTOPSY PERFORMED? ❑YES ® NO ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days tel 1 year before date ❑ Unknown Y pregnant within the past year ❑ Suicide ❑ Could not M 0 Pedestrian 0 Oliver (Specify)TO 21d. WERE AUTOPSY FINDINGS AVAILABLE COMPLETE CAUSE OF DEATH? 0 YES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction sits, etc. (Specify) 22d. INJURY AT WORK? ❑YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE Z 23a. DATE OF DEATH (Mo., Day, Yr.) April 10, 2013 El i 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH J�x 23b. DATE SIGNED (Mo., ay, Yr.) 11, 2013 23c. TIME OF DEATH 11:40 AM <' 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TB PRONOUNCED DEAD E theMApril 23d. To a best of my knowledge, death occurred at the time, dab and place and due to the cause(s) stated. (Signature and TIM) Isaac J. Berg, MD $$$ E ~ a ecpd at 24e. On e basis of examination and/or Investigation, In my opinion dth em the time, date and place and due to the ause(s) stated. (signature and TIM) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR 0 YES ® NO ❑ PROBABLY 0 UNKNOWN I ❑ YES ISSUE DONATION BEEN CONSIDERED? El NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES p NO 17. NAME, TITLE AND AD OF CERTIFIER (Type or PO Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE A. (�Q/v!� 28b. DATE FILED BY REGISTRAR (Mo, Day, Yr.) April 12, 2013