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<br />STATE OF NEBRASKA
<br />WHEN MIS COPY CARRIES THE RAISED SEAL OF STATE QF 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 dF` ISSVANCE
<br />2/10/2022'
<br />LINCOLN, NEBRASKA
<br />142202637 :
<br />A°f `i)(?;. R 1 1 044,,(1. kit 1 H.
<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. DECEDENTS NAME (First, Middle, Last, Suffix)
<br />Richard ' .Everett Green Sr
<br />4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />St. Edward, Nebraska
<br />. SOCIAL SeGURITY NUMBER
<br />505-32-6535
<br />8b. FACILITY -NAME (11 ftot Institution, give street and number)
<br />41,, The Heritage at. Saoewood
<br />ai
<br />8c: CITY OR TQWNOF DEATH (Include Zip Code)
<br />Grand Island :.68803
<br />8,
<br />0
<br />u
<br />c0
<br />2
<br />95. RESIDENCE -STATE
<br />Nebraska
<br />9d,.STREETANt NUMBER
<br />2812 Y(inston Circle
<br />10ai'MARITALSTATUS AT TIME OF DEATH ❑ Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />9b. COUNTY
<br />Hall
<br />5a, AGE - Last Birthday
<br />(Yrs.)
<br />11. FATHER'S -NAME :(First, Middle, Last, Suffix)
<br />Everett Green
<br />13: EVER IN U.S.ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) Yes 06/07/1948-12/07/1953
<br />15. METHOD OF DISPOSITION
<br />❑ Btn4al Ej Donation
<br />CrernflUo t Entombment
<br />❑ Ramovai ❑ OthelISpecify)
<br />91
<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 />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand. Island
<br />HOURS
<br />MINS.
<br />22 01772
<br />3. DATE OF DEATH (Mo Day, Yc)
<br />January 30,, 2022
<br />6. DATE OF BIRTH::(Mo., bay,Yl:)
<br />July 8, 1930
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />® Other(Specify)ASSISTED LIVING
<br />❑ hospice Facility
<br />8d. COUNTY OF DEATH
<br />Hall
<br />e. APT. NO. 9f. ZIP CODE 811 INSIDE DM LIMB'S
<br />68803 3 YES [ NO
<br />1Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Norma Jean Cook
<br />14a. INFORMANT -NAME
<br />Norma Jean Green
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Anne Case
<br />18b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />14b. RELATION:l:SP TO DECEDENT.:
<br />Spouse
<br />16c. DATE (Mo., Day,:Yr.),:
<br />February 1 2022
<br />STATE
<br />Nebraska,,
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska for
<br />Other (Specify).
<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 />IMMEDiaTECAUSE (Final a)Alzheimer's Dementia
<br />alai:woe of condition restrhing
<br />In deuth)::>
<br />Sequentially list conditions, a;
<br />any,leading to the cause Meted'
<br />on fine e
<br />Eet911he UNDEIM,YING GAvsE
<br />(disease or lnjuly$hat imtie(ed
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Adult Failure to Thrive
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />17b. Zip Code:;.
<br />6880'1
<br />APPROXIMATE INTERVAL
<br />onset to death:
<br />2 Years
<br />onset to death
<br />1 Year
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18.DART II, OTHgR SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART 1.
<br />Atrial i ibriIIS)(On
<br />20. IF FEMALE:'::
<br />❑ ;Not pregnant wtthfn peal year
<br />❑:,Pregnentattimeerdaath>.
<br />❑ ..Ngt pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />OUnknown HDntregnawithin the past year
<br />❑;
<br />" It:.
<br />22a, DATE•OF It±JURY (Mo ;;Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />rl Accident 0 Pending Investigation
<br />0 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 />onset to death
<br />19. WAS MEDIGALEXAMINER;: Et,j
<br />OR CORONER CONTACTED? •
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 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 LOCAT)ONtF INJURY: STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 30, 2022
<br />CITY TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />February 3;,2022 09:25 PM
<br />23d. Toahe best of mjt!knowledge, death occurred at the time, date and place
<br />rindduetelheeduse(s) stated. (Signature and Title)
<br />Gary Bettie, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP CODE;
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the ba8is of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Tile)
<br />25. DID TOBACCO USE... ONTRIBUTE TO THE DEATH?
<br />0 YeS ,ECI NA 0 PROBABLY 0 UNKNOWN
<br />f 27 NAMS,')9T(,E ANO ADDRESS OF CERTIFIER (Type or Print
<br />I Gait' Sett'e, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ❑ NO
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 7, 2022
<br />(:)
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