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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />11112/2021
<br />LINCOLN, NEBRASKA
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<br />202110055
<br />)6144,11
<br />SARAH BOHNENKAMP
<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. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Jeffery John Happold
<br />21 14957
<br />2. SEX
<br />Male
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7.; SOCIAL SECURITY NUMBER
<br />506-98-0207
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (1f not Institution, give street and number)
<br />Grand Island Regional Medical Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />55.
<br />Sb. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 inpatient
<br />ER/Outpatlent
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />October 16, 2021
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />May 16, 1966
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9d, STREET AND NUMBER
<br />2917 Idaho Ave
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />®YES (3 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married
<br />0 Married, but separated ❑ Widowed ® Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name
<br />11. FATHER'S -NAVE (first, Middle, Last, Suffix)
<br />James HaDooid'
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Marilynn Pavey
<br />13. EVER IN 1.1.8, ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Justin Happold
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />15. METHOD OF DISPOSITION
<br />Buttal © Donation
<br />Q Cremation ❑Entombment
<br />0 Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />16b. LICENSE NO.
<br />1495
<br />16c. DATE (Mo., Day, Yr.)
<br />October 16, 2021
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Cedarview Cemetery
<br />CITY / TOWN
<br />Doniphan
<br />STATE .
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING 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 />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 line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Phial a) Cardiorespiratory arrest
<br />disease orcof4itien TMultkty
<br />In deadly ...
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />online a.
<br />Enter the UNDERLYINO.CAUSE
<br />(dilater,or Injuiy that initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)shortness of breath
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />D)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />85 Minutes
<br />onset to death
<br />12-24 Hours
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />18. PART £I, OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />Unknown
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />YES ❑ NO
<br />.20. IF FEMALE:,
<br />ElNot prognentwithin peat year
<br />Pre(MOS at time of dse%:
<br />0 Net Pregnene, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑, Unknown Ifpregnant within the past year
<br />22a, DATE OF INJURY (Moly Day, Yr.)
<br />22d. INJURY AT WORK?
<br />OYES ONO
<br />21a. MANNER OF DEATH
<br />El Natural © Homicide
<br />0 Accident ❑ Pending Investigation
<br />❑ 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 />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES Q NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, ate.(Spite£ryi
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION:OF INJURY; STREET & NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23e. TIME OF DEATH
<br />23d. To the best of my: knowledge, death occurred at the time, date and piece
<br />and due tattle Cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES 0 NO 0 PROBABLY ® UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />October 28, 2021
<br />24b. TIME OF DEATH
<br />08:38 AM
<br />ZIP CODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />October 16, 2021
<br />24d. TIME PRONOUNCED DEAD
<br />08:38 AM
<br />24e. On the basis of examination andlor Investigation, in my opinion death ecrtUne l M
<br />the time, dote and place and due to the camels) stated. (Signature and Tale)
<br />Martin Klein, Hall Deputy County Attorney
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES ®NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Martin Klein, Hail Deputy County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />26b. WAS CONSENT GRANTED? r-�
<br />Not Applicable if 28a Is NO © YES NO
<br />28a. REGISTRAR'S SIGNATURE
<br />)4-11
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 4, 2021
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