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<br />WHEN = THIS CO
<br />ON
<br />CARRIES THE RAISED SEAL QF THF STATE OF NEBRASKA IT
<br />CERTIFIES THE : DOCUMENT BELOW TO BE . A TREJE GOPit 1r1F THE ORIGINAL REGORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES:. VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPO ORY FOR VITAL RECORDS
<br />r,>r7rrss�'ti
<br />TE 43F/SStIANCE
<br />8/17/2018
<br />LINCOLN, NEBRASKA
<br />'202205364
<br />RUSSELL FOSLER DEPARTMENT HEALTH AND
<br />INTERIM ASSISTANT STATE REGISTRAR 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 />Paul Earl Vierk:
<br />4. COY AND STATE O
<br />RRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand is)ant1, Nebraska
<br />15b:l3NDER 1 YEAR
<br />3a,A Last&rdhday.
<br />(Yrs )
<br />66
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />I0s.
<br />DAYS
<br />HOURS
<br />MINS.
<br />0288
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 9, 2018 s
<br />6. DATE OF BIRTH (Mt., Day. Yt.)
<br />November 21, 1951
<br />7. SOCIAL SECURITY NUMBER
<br />508-60-0301
<br />Dib: FACiUTY NAME(tf not Institution,"give street and number) •
<br />CFIi Health Si. Francis
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ atient
<br />I EInpI Outpatient
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />8c. CITY OR TOWN'OF DEATH'(Include Zip Code)
<br />Grand. Island. 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />8a.: RESIDENCE.STATE 's
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CfTY OR:TOWN
<br />Cairo
<br />9d. STREET AND NUMBER
<br />208 West. Egypt
<br />10a, MARITAL STATUS AT TIME OF DEATH I Married D Never Married
<br />0 Married. but separated D Widowed 0 Divorced 0 Unknown
<br />9e: APT. NO.
<br />9f. ZIP CODE
<br />68824
<br />9 ONSIDECITY r tMITS;
<br />® YES ❑ NO
<br />1Ob..NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Jana Young
<br />11. FATHER'S -NAME (Fi
<br />Glen Vierk
<br />Middle, Last,
<br />Suffix)
<br />12, MOTIlER`S-NAME (First, Middle,
<br />Winifred Donigan
<br />Maiden
<br />Surname)
<br />13. E1(ER IN U,S. ARMED FORCES? Give dates of service if Ye
<br />(Yes, No oT (Mk.) No >:
<br />14a. INFORMANT -NAM. E
<br />Jana Vierk
<br />14b. RELATIONSHIP TO DEGet/ENT,.
<br />Spouse ! .
<br />IIF METHOD OFOISPO$ITIION
<br />❑:Burial Q Dotiatlon .
<br />®. Cremation ❑ Entombment
<br />D;Ranovat ;;D Other(Specify)`
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17q:FUNERAL NOME •NAME AND MA LING ADDRESS (Street, City or Town, $tate)
<br />Abfei FurteratHome. 1123 W. 2nd. Grand Island, Nebraska
<br />CITY / TOWN
<br />Gibbon
<br />1te. DATE (Mo+.. Day, Yr:)'
<br />August 10, 2018
<br />CAUSE OF DEATH (See instructions and examples)
<br />TLig,otolh.@ clot oroents--diseases, injuries, or complications -that directly eauaed the death D0 NOT ettter tei»iinal events;such as cardiac amsst,
<br />pkatory afyest or ve thleular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only ane eauee to elide. Add additional lines if necessary.
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />in death}
<br />sequentiallylisteondifiena it
<br />any, leaded to the taut* laded'
<br />IMMEDIATE CAUSE:
<br />a) Unknown Natural Causes
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Systolic Heart Failure
<br />STATE..
<br />Neticas
<br />4Tb ZIp:Cade; .
<br />68801
<br />APPROXIMATE' INTERVAL
<br />onset tolleatit
<br />' Hour
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />Enter the UNDERLYING CAVE: c)
<br />(disease or injury bat Mater/
<br />Ing it death) >:
<br />' onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d),
<br />18. PART Ih OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART!
<br />Ischemic Dilated cardiomyopathy, Chronic Kidney Disease
<br />20,IFFEMA.E. '
<br />DNot pregnant wfhi i>=ft year
<br />0 Pregnant at time of death
<br />❑,: Not pregnant,; but pregnant Within d2 days of death
<br />Dr Neots ptagnant,but pregnant 43 days to 1 year before death
<br />tit..:Urdt.ithWijfieCiittig.helfilnerepastyear
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d ::INJURY AT WORtG?
<br />OY€S ONO
<br />21a. MANNER 0F'DEATH
<br />Natural ❑ Homicide
<br />0 Accident 0 Pending investigation
<br />0 Suicide ❑ could not ba delenninad
<br />21b, IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />;..
<br />0 Passenger
<br />❑ Pedestrian
<br />Other (Specify)
<br />19. WAS MEDICAL: EXAMINER
<br />OR CORONER CONTACTED?
<br />21c. WAS AN AUTOPSY.Pee
<br />❑ YEs ka No
<br />21d. WERE AUTOPSY FINDI..NGS AVAILABLE
<br />TOCOMPLETEL`AUStopee li?
<br />'0 YES ONO
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street factory, office building, construction site, etc. (Specify)
<br />220. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a DATE OF DEATH (Mo.; Day, Yr.)
<br />23b DATE SIGNED (Mo„ Day, Yr,)
<br />3E.10
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />the best of my knowledge, death occurred at the time, date and place
<br />due to the 'tau ae(s) stated. (Signature and Title)
<br />25. DID TOBADCD#SE t`C NTRIBUTE TO THE DEATH?
<br />YES [] NO , ❑ PROBABLY ® UNKNOWN
<br />STATE
<br />244. DATE SIGNED (Mo., Day, Yr.)
<br />Aug(uSt 9, 2018
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />August 9. 2018
<br />ZIP CODE 1 .
<br />24b. TIME OF'DEATH,
<br />12:51 AM
<br />24d. TIME PRONOUNCED DEAD
<br />12:51 AM
<br />24e. On the basis of examination and/or Investigation, in my opinion death occwred at
<br />the time, date and place and due to the cauae(s) stated. ($lgnatere and Title)
<br />Sarah Hinrichs, Hall Deputy County Attorney
<br />26a. HAS ORGAN OR TISSUa DONATION BEEN CONSIDERED?
<br />0 YES NO
<br />27. NAME, TITLE' AND ADbeeSS OF CERTIFIER (Type or Print
<br />Saralt Hinrichs, Hall Qeputy;County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />26b. WAS CONSENT GRANTED? r
<br />Not Applicable If 26a Is NO "OYES
<br />TRAS.
<br />8(GNATURE•
<br />28b. DATE FILED BY REGISTRAR
<br />August 14, 2018
<br />Day, Y
<br />CD
<br />
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