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STATE OF NEBRASKA
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<br />WHEN rms COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF TIIE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, WTAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OP!SSW IIICL
<br />5/15/2023
<br />LINCOLN, NEBRASKA
<br />202306628
<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 pEGEDENTS-NAME (FII•et, Middle, Last, Suffix)
<br />,lames Stafford Gook
<br />4. CITY AND STATE Oft TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Sf. Peterf.Minnesota
<br />7. SOCIAL SECURITY NUMBER
<br />468 508201
<br />6a AGE Laet Birthday.
<br />(Yrs.)
<br />8b. FACILITY -NAME (It not Institut]
<br />CHI Health:. St, .Francis
<br />give street and number)
<br />tic. CilY OR TOWN OF DEATH (Include Zip Code)
<br />Grand island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />4,0100 ..,4000.4-00g.„
<br />NUMBER
<br />3311 R saIaWn Drive
<br />9b. COUNTY
<br />Hall
<br />1Oa.'MARITAL STATUS AT TIME OF DEATH RI Married 0 Never Married
<br />Married, but separated OH/Wowed 0 Divorced 0 Unknown
<br />11 FATHER'S -NAME (First,
<br />Wlfred . Cook
<br />Middle, Last, Suffix)
<br />EItER IN U.S,: ARMED FORCES? Give dates of service H Yes.
<br />Yea, No, or Unk.) Yes 07/12/1963-07/11/1967
<br />16. METHOD OF DISPOSITION
<br />(]<Buttel Q Donation
<br />0Crematlonl; QEntombme nt
<br />�"`+'Removal ` ❑ Other (Specity)
<br />77
<br />fib :UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />8c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OFDEATH
<br />HOSPITAL © inpatient
<br />ER/Ou patient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />230
<br />3. DATE OF DEATH (Mo.Dtlty Yi';.1
<br />i.
<br />May 4, 2023
<br />5. DATE OF BIRTH:(MO. Day Yr.)
<br />May 29,,1945
<br />OTHER 0 Nursing Home/LTC'
<br />0 DecedenVs Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />8f. ZIP CODE
<br />68801
<br />Ifosp)ce Facility
<br />'9g INSIDE CITY miT,i `
<br />m YES ❑ NQ >;
<br />166. NAME OF SPOUSE (First, Middle, Last, Suffix) 1f wife, give maidennand/
<br />Mary Jo Morgan
<br />112. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Ratrica Stafford
<br />14a. INFORMANT -NAME
<br />Mary Jo Cook
<br />16a. EMBALMER -SIGNATURE
<br />Stacie 4 Cook
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Calvery Cemetery
<br />16b. LICENSE NO.
<br />1495
<br />CITY / TOWN
<br />St. Peter
<br />1Ta. FUNERAL;HOME NAME AND MAILING ADDRESS (Street, City or Town,. State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />13. PART I. Enterthe chain of sysnts- -dissaafs, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such u cardiac arrest,
<br />respiratory arrestor vehtdcular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a tine. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMAtSPk41'ECAuBEIPkiaU:; a) Respiratory Arrest
<br />wssase oetandhioarea«a
<br />kideON:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />aequemlailylistconditions, it. - blAcute on Chronic Combined Heart Failure
<br />any, leading to the; eauat listed
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Entaratet1NDERt 1NOoAuSE c)Hypovolemicshock
<br />(dresses or Injury that IMthtad
<br />resulthi5 in d
<br />OUE TO, OR AS A CONSEQUENCE OF:
<br />d)ACute Gastrointestinal Blood Loss
<br />14b. RELATION
<br />Spouse
<br />DECEaEAFT <'
<br />16c. DATE (Nle., Day yt.)
<br />May 13. goo
<br />STATE .
<br />nnesota
<br />1Tb. Zip Code.
<br />08801:
<br />PPROXIMATE INTERVAL`
<br />to ttooth
<br />2 Minutes
<br />; onset :t4ttleath
<br />10 Days
<br />onset
<br />12D
<br />ART I. 19. WAS MIrp /CAL L°)CAbilINE1i
<br />OR GORONI iR CONTACTED?
<br />Q YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ Yes I NO
<br />18 PART IL OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in P
<br />Chronic cotnbined heart failure, atrial fibrillation on chronic anticoagulation, hypertension, hyperiipidemia, coronary artery
<br />disease, Mitral Regurgitation, peripheral vascular disease, COPD
<br />20, IF FEMALE
<br />#!Ibi pMgntint kdadn Peat year
<br />0.. P eminent et mime of death:,;
<br />Ivot iir.gnattt .but pregnant within 42 days of duet
<br />0 Not pregnant, but pregnant 43 days to t year before death
<br />t idtoawn it ilidni lit rvl4vki the paid year
<br />DATE OF:tl 1URY ()Maya bay, Yr.)
<br />INJURY AT WORK?
<br />❑ YES ❑ NO .
<br />21a. MANNER OFDEATH
<br />Ea Natural ❑ Homkida
<br />0 Accident ❑ Pendlhg invxatigattpp
<br />pSuicide ❑ Could not be determined
<br />I
<br />22b. TIME OF INJURY
<br />214.1.E TRANSPORTATION INJURY
<br />❑ OflvodOperator
<br />❑� Paessnger
<br />u Pedestrian
<br />❑ Other(Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABE,E
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES ❑NO
<br />22c. PLACE -OF INJURY At home,:farm, street, factory, office building, constriction slte,'eti
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />P INJURY':*STREET & NUMBER, APT.NO.
<br />234. DATE OF DEATH (Mo., Day, Yr.)
<br />May 4, 2023
<br />CITY/TOWN'„
<br />236 DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Mai 12.2023 06:28 AM
<br />23d.
<br />ToWSW my! knowledge, :death occurred at the time, date and place
<br />and•due to tae closets) stated. (Signature and Title)
<br />Matthew Day, MD
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES red 610 PROBABLY 0 UNKNOWN
<br />27."NAME, TITLEAND'ADDRESS OF CERTIFIER (Type or Print)
<br />Matthew €)ay, MD,
<br />ziI
<br />4 >
<br />STATE
<br />oI11t)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b, TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD;.,
<br />3qe. GR the besle of examination andtor investigation, In my opinion desat oaaurred o(
<br />Sit time;'tlate and place and due to the causes) stated. (Signature and TItie)
<br />26a. HAS ORGAN OR TISSUE. DONATION BEEN CONSIDERED?
<br />❑ YES 1$11 NO
<br />2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO Q YES I
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 12, 2023 •
<br />OD
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