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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 />12/8/2017
<br />LINCOLN, NEBRASKA
<br />202109976
<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 />1715479
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Paul Joseph Short
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 3, 2017
<br />CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Lexington, Nebraska
<br />5a. AGE -Last Birthday
<br />Ctrs.)
<br />80
<br />6b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo. Day, Yr.)
<br />July 10, 1937
<br />7. SOCIAL SECURITY NUMBER
<br />508-44-5865
<br />lib. FACILITY -NAME (If Cwt 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 />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />EWOutpatient
<br />❑ DOA
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />0 Hospice Facility
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Adams
<br />9c. CITY OR TOWN
<br />Kenesaw
<br />9d. STREET AND NUMBER
<br />16867 West Denmand Rd
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68956
<br />90. INSIDE CITY LIMITS
<br />0 YES ®NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Truman Short
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) H wife, give maiden name
<br />Virginia Rae Lockwood
<br />12. MOTHER'S -NAME (First, Middle,
<br />Marjorie Sliger
<br />Maiden Surname)
<br />13. EVERIN U.S..ARMED; FORCES? Give dates of service If Yes.
<br />(Yes, NO, or Unit.) No
<br />14a. INFORMANT -NAME
<br />Virginia Rae Short
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑ Donation
<br />® Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />December 5, 2017
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />STATE
<br />Nebraska
<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 />17b.zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />46. PART 1 Enter the chain ter events --diseases, Injuries, or complkatons-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 />IMMEDIATE CAUSE (Final a) Intracranial Hemorrhage
<br />disease or condition resulting
<br />lin death)
<br />Sequentially list conditions, if
<br />any, Medin9 to the Gine fisted
<br />Tine a
<br />on
<br />Enter the UNDERLYING CAUSE
<br />(disease orkdurythat Init)ated
<br />the events resulting in Mash)
<br />LAST'I
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />APPROXIMATE INTERVAL
<br />onset to death .. ...
<br />Week
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<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 />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES 0 NO
<br />20. IF FEMALE:
<br />0 Not pregnaetawithin past year
<br />0 Pregnant at time of death
<br />❑ Net pregnam, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before Math
<br />0 Unknown ifpn.gnant whin the past year
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be detemllned
<br />21b, IF TRANSPORTATION INJURY
<br />0 Driver/operator
<br />❑ Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?::.
<br />❑YES 0 14
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />DYES No
<br />22b. TIME OF INJURY
<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 />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 3, 2017
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 5. 2017
<br />CITY/TOWN
<br />23e. TIME OF DEATH
<br />04:55 PM
<br />3d. To the best of my knowledge, death occurred at the time, date and plata
<br />and due to the cause(s) stated. (Signature and TPM)
<br />Sanjeev Wasson, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES J NO 0 PROBABLY 0 UNKNOWN
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24e. 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, M my opinion death occurred at
<br />the tree, date and place and due to the cause(s) stated. (Signature and Tine)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 0 NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Sanjeev Wasson, MD, 816 22nd Ave., Suite 100, Kearney, Nebraska,
<br />28a. REGISTRAR'S SloNATURE
<br />28b. DATE FILED BY REGISTRAR OWN., Day, Yr.)
<br />December 7, 2017
<br />1
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