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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 OFISSUANCE
<br />6/14/2021
<br />LINCOLN, NEBRA:
<br />2022(i3016
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTR
<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 />John Paul Rose Sr
<br />4 CITY AND STATE OR>TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska'"
<br />7: SOCIAL,EECURfl. NUMBER
<br />508.80.3 i3z
<br />5a AGE • L
<br />(Yrs.)
<br />73
<br />Sb:. FACILITY NAME $ f not Institution, give street and number)
<br />Tiffany Square Gare Center
<br />8C�CITY ORTOWN OFAEATH'(Include Zip Code)
<br />grand tslaltd 68803
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />9d:BTREET.. . D NUMBER
<br />4218 Spur Lane
<br />•
<br />Birthday
<br />5bUNDER 1 YEAR
<br />21 07484
<br />2. SEX 3. DATE OF DFATH (Mo., Day, Yr l
<br />Male June 5, 2021.
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpadent
<br />ER/Outpatient
<br />❑ DOA
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married •
<br />0 Married, but separated. ❑ Widowed 0 Divorced 0 Unknown
<br />FATHER'Si4AME (1
<br />Clement Peter
<br />Addle, Last, Suffix)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />10b. NAME OF SPOUSE (First,
<br />Janet Ruth Hartman
<br />1& EVER IN:H.S. AHMED;FORCES? 'Give dates of service if Yee.
<br />(Yes, No, or Unit.) No
<br />15. METHOD OF DISPOSITION
<br />08urlai [Donation
<br />oa Creunadon QEntomnbment
<br />Ei.ftemoVer © Other (Specify)
<br />112. MOTHER'S -NAME (First, Middle,
<br />Dorothy Louise Reynolds
<br />6c. UNDER 1 DAY
<br />HOURS MINS.
<br />6. DATE OF BH Th (Mo., Day, Yr.)
<br />June 18,i1947::
<br />OTHER 50 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />8g: IIIISIDE CtTY LIMITS
<br />P1YES No"
<br />Middle, Last, Suffix) If wife, give maiden name
<br />14a. INFORMANT -NAME
<br />Janet Ruth Rose
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a, FUNERAL: HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State)
<br />Afil FaithsFuneral Home, 2929 S. Locust Street, Grand Island; N
<br />raska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />4b. RELATIONi
<br />Spouse
<br />P TO'DECEDENT
<br />16c. DATE ifilo.,.Qay, Yr.)
<br />June 8 1
<br />CAUSE OF DEATH (See:itstrt,ttstl
<br />and exa
<br />alts moles)
<br />18. PART I. Enter the Chain of events- v0seases, Injuries, or complications -that directlycaused the death. DO NOT enterterminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular ladralation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Ones If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAil9E iPlnal ..
<br />disease ar condfllon resuatn9
<br />a) Respiratory Failure
<br />I144.1°4 DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list condition,if b)Abdominal Malignancy
<br />any, leading to the cause listed
<br />on Una a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that tnitbted
<br />the events resulting In
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />STATE
<br />Nebraska
<br />17b::Zip Cptt@;;>:
<br />6880:1
<br />APPROXIMATE INTERVAL
<br />ttID death
<br />onset t0 death
<br />5 Months
<br />le. PART II.OTHER SIGNIFICANT CONDITK)NS-Conditions contributing to the death but Rot r
<br />a 20. IF FEMALE;
<br />E t QNotpregnant*MOO pestyear
<br />0 Pregnant at:time of Medi
<br />©: Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unhnovmir.pregnsntwkhin the past year
<br />A
<br />22d. INJURYAT WORK?
<br />,.EI YES DNO.
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident D Pending hweatigaeen
<br />0 Suicide 0 Could not be determined
<br />r underlying cause given in PART L
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Odver/Operater
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />19. WAS MEDICAL. EXAM.NER::
<br />OR CORONER CONTACTLD9
<br />YES No
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES Ntk
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE`
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES D NO;::.;.
<br />22c. PLACE OF INJURY -At home farm, street. factory, office building, constructs
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />LOCAT(O!('.OF 11N JURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 5. 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />June 7..2021
<br />5.
<br />1
<br />sibs, etc,.(3
<br />CITYITOWN
<br />23c. TIME OF DEATH
<br />08:30 AM
<br />7otht best of my knowledge, death occurred at the time, date and place
<br />Bird dueto the camels) stated. (Signature and Title)
<br />Isaac J. Berg. MD
<br />26..DID TOBACCO USECONTRIBUTE TO THE DEATH?
<br />YES :'D NO . [Q PROBABLY I UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (510., Day, Yr.)
<br />24b. TIME OF DEATH
<br />tP CODE <;
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />248, On the basis of examination and/or investigation, in my opinion dm%Il occurme at
<br />die time. date and place and due to the cause(s) stated. (61Mraturo ami T I.).:
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YEE j4 NO
<br />27 <NAME, T('r E AND ADDRESS OFrCERTIFIER (Type or Print
<br />• %Isaac J. Berg, MD 729 North Custer Avenue, PO Box 2339,•Grand Island, Net>raska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONS
<br />Not Applicable if 26S sty
<br />28b. DATE FILED BY REGISTRAR (Mo, Day, Yr.)
<br />June 8, 2021
<br />
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