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<br />STATE OF NEBRASKA
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<br />HEN- no TNIS !'"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'1SSLIANCE
<br />12/18/2017
<br />LINCOLN NEBRASKA
<br />j,.DECEDENVS.NAME (First'. Middle,
<br />Jay Curtis' Stoddand
<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 />Last, Suffix)
<br />4 CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH IBa. AGE . Last Birthday
<br />Eustis, Neb€aska 87
<br />SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />T:
<br />506-28-814.4
<br />UN )ER;1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />FAQILITY NAME (If foot institution, give street and number)
<br />!GO ad antaritan.SoC sty -Grand leiand Village
<br />11.1
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />P.. Grand island. 68803
<br />9a RE$IbENIr'ATE
<br />Nebraska`
<br />STREET AND'NUMBER
<br />1810 W. Charles Street
<br />2
<br />9b. COUNTY
<br />Hall
<br />DAYS
<br />HOSPITAL ❑ Inpatient
<br />❑ ERfQutpatlent
<br />❑ DDA
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 12, 2017
<br />6 DATE OF BIRTH (Mo.,;DaWyr:),.
<br />February 12, 1930
<br />OTHER blj Nursing Horne/LTC [] Hospice Facility
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Sc.CITY Oil TOWN,
<br />Griiirid island
<br />9e. APT. N
<br />O. 9f. ZIP CODE t 11 S,DE CilY.tUMffS
<br />68803 1 Eras El NO
<br />Last, Suffix) If wife, give maiden nam
<br />ARtTAL STATUE AT TIME OF DEATH l] Married 0 Never Married
<br />Married, butsepeteted © Widowed::: 0 Divorced 0 Unknown
<br />1. FATHER'S -NAME (Fist, Middle, Last, Suffix)
<br />Fred Stoddard
<br />3. EVER IN U S :ARMED FORGES? Give:0408'd service if Yes.
<br />(Vas', No or Unk4 f%,p
<br />45. METHOD OF:tifSSPOSITlON
<br />EJ Bursa, [] Donation
<br />[] Cremation Q Entombment
<br />❑ Removal ` :❑ Qther (Sl+ec y)
<br />1Db..NAME OFSPOUSE (Ftst, Middle,
<br />OorothY . Jean Hosek
<br />it MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Amelia Hansen
<br />14a. INFORMANT -NAME
<br />Dorothy Jean Stoddard
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L. Ruiz
<br />16tk LICENSE NO.
<br />1495
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Ord City Cemetery
<br />14b REt.ATI0NS#IfP TO DECE!
<br />Wife
<br />16c. DATE (Maa, 81ay,°Yr.)
<br />December 16, 2017
<br />STATE
<br />Nebraska
<br />CITY I TOWN
<br />Ord
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town. State)'
<br />All Faiths Funeral Horne. 2929 S. Locust Street. Grand Island." Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />PART t Eater U% Ghee of events- .diseases, injuries, or complications -hat directly caused the death, DO NOT enlaylanlitats events such as carelac arrest,
<br />r eplratOfy atrea& or rte !erliegen without shovdng the etiology. DO NOT ABBt Est .IE. Otter only one cause on a IIne. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a}Alzheimers Dementia
<br />1Tb w+i i1#....Cock
<br />801
<br />Ud
<br />EDIATE CAUSE (Final
<br />disease a candaion reeuMne.
<br />death)
<br />DUE TO, ORAS A CONSEQUENCE OF:
<br />tiltlaIy liar cecau b)
<br />dinpllp the:.oause tefatt, --
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYINO CA. USE c)
<br />{t6se eofin(uryihatiniaated>
<br />le evetrla resuNhp:tn dealt) D) UE TO, OR AS A CONSEQUENCE OF:
<br />,LAST .
<br />APPROXiMATONISRMAL
<br />onset telie?6jt.
<br />Years "
<br />onset t tSeBek>:`
<br />onsetto death
<br />L 19. WAS MEDICAL EXAMINER
<br />OR CORONER CCf3eITACT.E0?
<br />❑ YEa No'<
<br />21c. WAS AN AUTOPSY PERFORMEt1 !
<br />❑ YES ®No
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Condkbns contributing to the death but not resulting in the underlying cause given in PART
<br />poronafy Arter;j. Disease, Diabetes Mellitus Type 2, Hypertension, Hyperiipidemia
<br />0. tilfErAttikiip
<br />❑ Not piegnara Y plain past year
<br />Pregnant at time of death
<br />f p e nan2,:tRa pragnarat: Within 42 days ofideath.
<br />anti:but pre nent:43 days tot year before death
<br />o Unkndam tf pt mats ydrhin the past year
<br />•
<br />2a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d ::INJURY ATIEORK7
<br />h0�
<br />]YES ONO
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />Accident 0 Pending Investigation
<br />❑ Suicide ❑ Could;!wt be determined
<br />22b. TIME OF INJURY
<br />211. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />Cl pedestrian
<br />other (specify)
<br />21d. WERE AUTOPSY FIND.NGS AYj
<br />TO COMPLETE PAUSE OP p1 AT
<br />❑ YES ❑ NO it
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />. LOCATION OF INJURY • STREET 8i NUMBER, APT.NO.,
<br />321E OI» DEATH (Mo., Day, Yr.)
<br />Decerrlber12, 2017
<br />CITY/TOWN
<br />DATE SIGNED 1340... Day, 23c. TIME OF DEATH
<br />December 73.2017 06:43 AM
<br />2d. Tothe best of my'know edge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Tine)
<br />ay C, Anderson, MD
<br />ID TOBACC ? USE. 08 RIBUTE TO THE DEATH?
<br />❑ YES ® NO ❑ PROBABLY UNKNOWN
<br />STATE
<br />24a. DATE; SIGNED (Mo., Day, Yr.)
<br />:24o. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME
<br />24e. On the basis of examination and/or Investigation, in my opinion foam ecctarsd at
<br />the titre, date and place and due to the cause(s) stated. thirster* and TMs)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES El NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jaye Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />REGISTRAR'$ SIGNATURE
<br />26b. WAS CONSENT GRANT
<br />Not Applicable if 28a Is NO
<br />28b. DATE FILED BY REGtSTRA*(MO, Dayt.Yr
<br />December 14, 2017
<br />
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