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<br />WHEN 7HlS :':COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTYI ES TYlE DOCUMENT BELOW TO BEA TRUE 'COPD :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 V I.TAL REOOR.PS •
<br />DATE OFISSUANCE .
<br />10/302019
<br />LINCOLN, NEBRASKA
<br />202207 348
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />• STATE OF NEBRASKA - DEPARTMENT 0I HEALTH:; ANDHUMAN SERVICES
<br />CERTIFICATE iOF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Jerold Edward Dingwerth
<br />CI
<br />;ANRSTAIE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand:islaritt, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506-60-6323
<br />Stk AGE -Last Mir
<br />{Yrp )
<br />71
<br />FACILITY -NAME WOO institution, give street and number)
<br />CMI Health SY Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand. Island 68803 •
<br />RESIDENCE4TATE
<br />Nebraska
<br />STREET AND NUMBER
<br />4013 Kay Ave
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married I
<br />10b NAME OF SPOUSE (First, Middle, Last,
<br />Merited, butseparaters 0 Wido+rod ,0 C :•rerl 0 unknown r o:Ina ligaa Schioman
<br />9b. COUNTY
<br />Hall
<br />r UNDER.1 YEAR
<br />MQS -DAYS
<br />Sa. PLACE OF DEATH
<br />HOSPITAL RI Inpatient
<br />0 E
<br />© DOA
<br />t C1TY OR I'DWN
<br />Grand'Island
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />HOURS MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />October 17, 2019
<br />OTHER 0 Nursing Home/LTC 0 Hospice FacNlty
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />Ed, COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />11 FATHENS-NAME (First, : Middle, Last, Suffix) 11 MOTHER'S -NAME (First, Middle,
<br />Edward Dingwerth Shirley McGuire
<br />3, EVER IN U S ,ARMED:: FORCES?
<br />(Yes Noo• or ljnk) N{
<br />Give dates of service if Yes.
<br />14a. INFORMANT -NAM€.:,.
<br />Donna Mae DI0t1We' tie
<br />14b. RELATIONSHIP TO mpg
<br />Spouse
<br />16 METHOD.OFOISPOSl11ON
<br />❑goal. 0 Donation
<br />® Cremation 0 Entombment
<br />D Removal ,[0 Qiher:(Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />16ti'UCENSE'NO.
<br />CITY / TOWN
<br />Gibbon
<br />16c. DATE (Mo Day, Yr.-)
<br />October 21 2019
<br />STATE
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />1711 Zip Com
<br />68801
<br />CAUSE OF DEATH .(See instructionsand examples)
<br />& PART IPART L Enter thecchain Sir of events .dlseeaea injuries, or compitcallOnslhat directly caused tile death pis NOT enno:germinatiMats suCh 5$ cardiac arrest.
<br />respiratory arrest, or ventrltu(ar Sbrillation without showing the etiology. DO NOT ABEREVIATE. Enter only One Cause nil a knit Add additbnpl Kass if neves
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Acute Hypoxic Respiratory Failure
<br />disease or cot dation resulting
<br />death)
<br />Sequenfaily snit yoMeKdona. it
<br />any; leading to the:cause Listed 4
<br />on line is .. ..
<br />Enter the UNDERLYING CAUSE
<br />rdiseasa trr iHurY,ikiM initiated::::.
<br />the events resasing in dead)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Acute Hemorrhagic Brainstem Stroke
<br />APPROxIMAi'm
<br />onset todaath
<br />Hours ' .. .
<br />onset to dealt/;
<br />Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />onset to death
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS-Condltrois contributing to the death but not resulting in the underlying cause given in PART L
<br />1L WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />D yes
<br />20.IFFEMA4E
<br />... 0. Not Pregnant akhin a' past year
<br />0 Pregnant at time of death
<br />Hart patignagt,:but pregnant within 42 days of death •
<br />Nut pregnant, but pregnant1
<br />3 "y110
<br />arito 1 year before death
<br />... m If pMdnant wrtttu ne war win
<br />21a. MANNER OF DEATH
<br />® Natural 0 Hodak:ids .
<br />D Accident 0 Pending investigation
<br />D Suicide 0 could nOt be dels*Mlned
<br />21i;� 1F' TRANSPORTATION INJURY
<br />0 Driver/operator
<br />0 Passenger
<br />lapedestrian
<br />Cliptoor.:(SPecNY)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />DYE ®Nd
<br />21d. WERE AUTOPSY FINDINGS AVA1(ABL
<br />TO COMPLETE CAUSE OF DEATNI:.
<br />s"DYet DN
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />114JU RY.:.: AT WORK?
<br />YES•. N©...;::
<br />22b. TIME OF INJURY ' 22c. PLACE OF INJURY -At
<br />me, farm, street, factory,
<br />bttU�ng, correlwitoihr sig etc. (Specify
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />,17AT'E O5DEITH(Mo., Day, Yr.)
<br />October: 1.:' ,2019
<br />b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />October 21. 2019 04:46 PM
<br />3d. To the best of my knowledge, death occurred at the time, date and piece
<br />and due to the cause(s) stated. (Signature and TWO
<br />Vinay K. Singh. MD
<br />8, DID TOe'?ACCO USE CONTRIBUTE TO THE DEATH?
<br />D YES D NO ® PROBABLY- 0 UNKNOWN
<br />.pF
<br />T .SIGNED (Mo., Day, Yr.)
<br />ZIP COOS
<br />OUNCED DEAD (Mo., Day, Yr;f
<br />24b. TIME OF
<br />24e. On are basis of examination and/or hnvesmgstien, kimy opte)an dear occurred at
<br />the time, date and place and due to the cause(%) stated. (ignetrre and Ree)
<br />•
<br />26e HAS ORGAN.E R TISSUE DOHA'flON M
<br />❑ YES
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Vin ay,K. Singh, MD, 2620 W Faidley Avenue, Grand Island, Nebraska,:68803
<br />REGIS- $ SIGNATURE
<br />CONSIDERED?
<br />NTGRAliT&i3?
<br />Not Apple if 26e M NO D: ES
<br />28b. DATE FILED BY
<br />October 25, 2019..
<br />IN.:Dety.3fr.);
<br />
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