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WHEAf < THIS' COPY CARRIES THE RAISED SEAL OF • THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE . A TRUE COPD' OF THE .ORIGINAL RECORD -
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, Vii$.
<br />•
<br />p..g.popps..pgicE, WHICH IS THE LEGAL DEPOSITORY:FOR:VITAL:RECORDS
<br />DATE OFISSfIANCE 201304330 RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />L IVcOLN,
<br />5/20/2019IY202402913 DEPARTMENT OF HEALTH
<br />NEBRASKA AND HUMAN SERVICES
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTN'AND I OMAN SERVICES •
<br />CERTI ICA CSP DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Roy Charles Allan Hopkins
<br />1 CITl.: *:STATE 01R TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand lslartel, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />50040-5331
<br />Sa AG(a Leet 8irtitday
<br />SD FACILITY NAME (If not Inetibe8on, give street and number)
<br />CHI Health at Francis
<br />• 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand :.island . 6866.03
<br />if RESIDENCE4TTE
<br />gc1, STREETANONUMBER
<br />912 N. Evans St. .
<br />10a MARITAL $TATS AT :TIME OF DEATH §a Married 0 Never Married
<br />C} allied butsepmatee[ C( Widowed 0 Divorced 0 Unknown
<br />. FA'FHEir'S-NAME iFirst, Middle, Last, Suffix)
<br />Delmer Hopkins
<br />13 EV:ER IM U S ; RRMgfl F.O. RCEs? ave dates of service if Yes.
<br />(Vas Nor* fkik a
<br />3b UNDER::1 YEAR
<br />MOS,
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 inpatient
<br />fah: El iOuRtalient
<br />DIA
<br />Sb. COUNTY
<br />Hall
<br />1lf. METHOD:OF EISPOSRTIGtN
<br />[} eudai "'[] D6natkm
<br />) Cremation 0 Entombment
<br />;0.Omoval ' Q Outer t5PecI y)
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE
<br />May
<br />DEATH (Mt., Day. Yr.)
<br />12, X018'
<br />8. DATE OF Bittnti p.:THM Yt i'
<br />8d. COUNTY OF DEATH
<br />Hall
<br />''SC CIlY OR TOWIN:.
<br />Grand :island
<br />Be. APT. NO.
<br />:18b.NAME OFSPOUSE::(First, MIddle, L
<br />Debbie Whiter ..
<br />BI. ZIP CODE
<br />68801 ®a0,4Natiaa CretteraTte:
<br />Vas 0 NO.
<br />Suffix) If wife, give tttaid•s•n ntree::
<br />I12. MOTHER'S -NAME (First, Middle, Malden snow*
<br />Betty Reimers
<br />14e. INFORMANT -NAME.
<br />Debbie Hopkins
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b, LICENSE NO.
<br />14b. RLR.A
<br />IMfe
<br />earp.10 D *T
<br />18C: GATE 0k4.0 ,!!Vr,i:
<br />May 10 2019
<br />led, CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Service's
<br />Ta. FUNERAL T OME NAMEAND MA LINO ADDRESS (Street, City or Town SYatrIL
<br />All Faiths Funer'at Home, 2929 S. Locust Street. Grand Island, Nebraska
<br />1tti:` Cada
<br />68801
<br />SAUSE OF DEATH (See ipstructIons and examoles)
<br />B PAR1'l Bode the:&ball of evInta- dlaeases, intones, or comptkations4hht directly caned t e death, DONOT.,ater fiNnlinal waots such as cardiac arrest,
<br />1*apWeWtli ureal or nlnifl ultr fibrillation without shoving the etiology, DO NOT ABBREVIATE Enter only one Cluae: pit a Iine:Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE fPinal a) Undetermined Natural Causes
<br />disease or condition retuning
<br />quP Ilasy•)la
<br />uPlfitir:tw
<br />Inti
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />UUE TO, OR AS A CONSEQUENCE OF:
<br />Enter thefiNDERLYsio CAUSE C}
<br />iOtseott ter ddsr ll *M. inlr10e0
<br />iia 4na'nts tliukifiygan death) ;;:DUE TO, OR AS A CONS
<br />d)
<br />QUENCE OF:
<br />const he death •
<br />18. PART Ii. OTHER SIGNIFICANT CONDITIONS.Candkions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Acute Kidney Injury, Hyperkalemia, Chronic Obstructive Pulmonary Disease
<br />20. ItRFEMALE
<br />Not t4gnant tnthin Ott year
<br />© Pregnant at time of death
<br />Not PFRRgnaalt::hut pr sitant.wratin a2 days or death
<br />Not pregnant;but prsgnain 3 days to 1 year before death
<br />1Jnnnown if posswkwIrkin tits past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />D YES Q N0
<br />}
<br />21a. MANNER OF DEkTH
<br />Natural 0 NemlCide
<br />© Accident Cl Panding investigation
<br />0 Suicide Uphill bsdotmlitled •
<br />22b. TIME OF INJURY
<br />2117 IF TRANSPORTATION INJURY'
<br />© Oifver!Operator
<br />ID Passenger
<br />[D Pedestrian
<br />°th"(spacnyf
<br />1 I WAS MEDICAL MINER
<br />OR CORRNRR cCNTACTEDT
<br />0Yfa . .. ?
<br />21e. WAS AN A
<br />© Yes
<br />NO
<br />21d. WERE AUTOPSY FINS AVARAB4E
<br />TO COMPLETE CAUSEdF f)fiATifF ;,
<br />0 yes
<br />22e. PLACE OF INJURY -At home, farm, street, factory, office building, constrtstlon efts, USC.(SPecify)
<br />22e, DESCRIBE HOW INJURY OCCURRED
<br />. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />TATE
<br />DATE OF fseA7H(Mo., Day, Yr.) •
<br />23b DATE SIGNED Mo., Day, Yr.)
<br />23c, TIME OF DEATH
<br />the time, data and place
<br />r.sueufaf r*Ne0 !SI one:r1s ]n. TIM;
<br />DID TQi3ACOO,USE CONTRIBUTE TO THE DEATH?
<br />0 YEs 0 NO 0 PROBABLY l UNKNOWN
<br />21. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Daue:Med(in, Halt Attorney, 231 S. Locust, Grand island, Nebraska 6
<br />r$#T .: Sl,ONED (Mo., Day, Yr.)
<br />May13;2019
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />May 12. 2019
<br />DI51.714
<br />0115AA:
<br />24d. TIME P*ONOUt1C ED
<br />01:1 AM
<br />24e. On the basis of erSo herbs t endaor invesfMMian, In any opirton Meth Q.:zoned at
<br />the tom, dads and piste end due to the cauaai(s) s*tsrL_Ole'sknsen0 TEN
<br />Dave Medlin, Hall County Attorne
<br />28a. HAS ORGAN OR TISSUE DONATION BSACONSIDERED?
<br />Q YES gl NO
<br /><REGISTRAR'S SIGNATURE
<br />26), WAS QttSE
<br />Applied H286le NO
<br />28b. DATE FEED Orr Ri
<br />May 16, 201/9
<br />
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