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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 />20210'756
<br />1/31/2017
<br />LINCOLN NEBRASKA
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />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 />Jerry Mack Pierce II
<br />4 CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Germany
<br />7. SOCIAL SECURITY NUMBER
<br />453-29-7616
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />56
<br />8b. FACILITY -NAME (If riot institution, give street and number)
<br />CHI Health::: Nebraska Heart
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />0 DOA
<br />u
<br />W -
<br />(Y
<br />O
<br />x
<br />9d. STREET AND NUMBER
<br />u.
<br />a 908 W. 5th Street
<br />a10a. MARITAL olAT J ' AT SMC OF DEAl:i J married 0 Never Married I lob. NAME OF SPOUSE (First,..
<br />L...1 Married, but separated ❑ Widowed ❑ Divorced 0 Unknown Tamothy Jo Williams
<br />d
<br />2
<br />0
<br />r
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Lincoln 68526
<br />8a. RESIDENCE$TATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />11. FATHER'S -NAME (Mat, Middle, Last, Suffix)
<br />Jerry Mack Pierce I
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or sank.) Yes 1978-1982
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />® Cremation 0 Entombment
<br />❑;Removal .0 Other:(SPecify)
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 14, 2017
<br />6. DATE OF BIRTH (MO.,>Day, Yf.)
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />Q Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Lancaster
<br />9c. CITY OR TOWN
<br />Grand Island
<br />14a. INFORMANT -NAME
<br />Tamothy JO Pierce
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />9a. APT. NO. I 9f. ZIP CODE I 9g. INSIDE CITY LIMITS
<br />68801 ® YES 0 NO
<br />Middle,
<br />12. MOTHERS -NAME (First, Middle,
<br />Shirley Ann Shelby
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, Stats)
<br />AllFaiths Funeral Home. 2929 S. Locust Street. Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />Maiden Surname)
<br />14b. RELATIONSHIP TO DECEDENT:
<br />Wife
<br />16c. DATE (Mo., Day, Yr.)
<br />January 18, 2017
<br />STATE
<br />Nebraska
<br />17b. 2ipCode
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />PART 1. EttfOr the: chain of events -diseases, Injuries, or complications -that directly causedthe death. DU NOT enter temtinal events such as cardiac arrest,
<br />respiratory arrest, of ventrthelsr fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a lin.. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Multiorgan Failure
<br />disease or condition resulting
<br />In death)
<br />S.quexlally get }iOi tIons,if -i b)Thrombosis Of Left Ventricular Assist Devicei
<br />any. leading 3d' the::Csiale Wad.;:.; - _...
<br />on line a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE D) Ischemic Cardiomyopathy
<br />(diseaseor Iry'ury01,0 Initiated
<br />..... v .... ..... ..... .. _...
<br />the cycles resultingin death) ;>
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART!.
<br />Coronary Artery Disease; Chronic Obstructive Pulmonary Disease; Ventricular Tachycardia; Chronic Kidney Disease
<br />u- 20. IF FEMALE:
<br />0 Not pregnant within past year
<br />lZ
<br />IL 0 Pregnant at time of death
<br />Not Prognant,.but Pregnant within 42 days of death
<br />Nol
<br />~ant, but pregnant: 43 days to 1 year before death
<br />LJ voknowtn 11 Pra6nanr withtb the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d..INJURY AT: WORT'
<br />YES ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident
<br />0 Suicide
<br />22b. TIME OF INJURY
<br />❑ Pending Investigation
<br />0 Could not be determined
<br />21b. IF TRANSPORTATION INJUR
<br />❑`Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other(SPecIN)
<br />APPROXIMATE:: INTERVAL::;
<br />onset to death
<br />6 Hours
<br />onset to death
<br />3 Weeks
<br />onset to death
<br />6 Years
<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 CAUSEOF DEATH7.:
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />33m. DATE OF DEATH (Mo., Day, Yr.)
<br />JarivarY 14; 2017
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />January 18. 2017 06:45 PM
<br />2d. To the best of my knowledge, death occurred at the time, data and place
<br />end due to the mantels) stated. (Signature and Title)
<br />Sagar S. Damle, MD
<br />25. 010 TOBACCOUSECONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY ® UNKNOWN
<br />STATE ZIP CODE''
<br />240. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or Investigation, In my opinion death occurred at
<br />the time, data and place and due to the auss(s) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE r • ATION BEEN CONSIDERED?
<br />® YES ■ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Sagar S. Oamte, MD, 7440 S 91st St, Lincoln, Nebraska, 68526
<br />26a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑ YES el NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 23, 2017
<br />
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