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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA, DEPARTMENT
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSIT
<br />DATE OF ISSUANCE
<br />08/04/2015
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND
<br />CERTIFICATE OF DEATH
<br />202404729
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Gary Joe Berta
<br />4.- CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Broadwater, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-48-2865
<br />-1504339
<br />5a. AGE - Last Bkthdsy 6b. UNDER -1 VE 5c. UNDER1 DAY
<br />(Yrs.)
<br />77
<br />Ib. FACILITY -NAME (If notlrlstituNon, give street and num er)
<br />CHI Health St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />Os. RESIDENCE -STATE
<br />Nebraska
<br />ed. STREET ID4Et4UMBBR
<br />2707 W. Louise
<br />Bb. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Joseph Andrew Berta
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />0 Burial 0 Donation
<br />Cremation 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />MOS. '
<br />DAYS J HOUR$:
<br />8a, PLACE OF DEATH
<br />)HOSPITAL [ Inpatient
<br />❑ 17trOutpatent
<br />❑ DOA
<br />9c. CItYOR TORN
<br />Grand Island
<br />MINS.
<br />rTB't¢ ISERTtt (Mo., Pay, Yr.)
<br />, �, 25 2016.
<br />s OA1' l ai*TN lin. , oay, Yr.
<br />February:12,` 1938
<br />OTHER tgi Nursing Home/LTC ' "Q iiDspIcb tricmty.
<br />0 Decedent's Homs
<br />Q Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Halll
<br />8s. APT. NO.
<br />er ZIP coda
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last Suffix) If wife, give maids* dente
<br />Billie Jean Austin
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Nadine Annette McKibbin
<br />14a. INFORMANT -NAME
<br />Billie Jean Berta
<br />14b. RELATIONSHIP TCDECEOiNT
<br />Wife
<br />Ric. DATE (Mo.,
<br />July 28, 2015-
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />18b. LICENSE NO.
<br />CITY 1 TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and exarnplits)
<br />ie. PART 1. Enter the chair of events -disuses, injuries, or compllcatons4hat directly caused the death. DO NOT enter terminal tonnes such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only ons cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Metastatic Adenocarcinoma Prostate
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />in death)
<br />Sequentially fist conditions, If
<br />any; leading to the cause listed
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury that initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />STATE
<br />Nebraska
<br />17b. zip Code
<br />68801
<br />APPROXIMATE MERVV
<br />onset tQdeath
<br />Chront
<br />Onset tO death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />1- onset to death"
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given Int
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />0 Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown If pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES [I NO
<br />21a. MANNER OF DEATH
<br />® Natural. ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b.IF'TRANSPORTATION INJURY
<br />© odveuDeorstor
<br />❑_Passenger
<br />❑-Pedestrian
<br />❑ Other (specify)
<br />PART I. 16. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?QVeS ,; IAF Kt
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />YES NC
<br />21d. WERE AUTOPSY FINDINGS AVM
<br />TO COMPLETECAUSEOFAEATH?
<br />❑ YES W N0 ...
<br />22c. PLACE OF INJURY -At home, fads, skeet, factory, office buUding, construction like, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />224. LOCATION OF INJURY STREET 1. NUMBER, APT.NO, CITY/TOWN
<br />23a. DATE OFDEATH (M0. Day, Yr.)
<br />July.25, 2015
<br />23b. DATE IGNED (Mo., Day, Yr.) 23c. TIME OF. DEATH
<br />July 27, 2015 10:25 PM
<br />4.7o the test of my knowledge, death occurred at the Sims, date and place'
<br />and due to the cause(s) stated. (Signature and Tido)
<br />Ryan D. Crouch, D0
<br />STATE
<br />24a. DATE S GNIX .(ie.r Day, Yr.) -
<br />24c.PRONOUNCED DEA1.IMO, Dai N%)
<br />a4l►.:Tt11it'S%doodsf
<br />2Ad.11M `iRE�tD,�d
<br />24e. On the basis of exnllllhtiot •Mast ihrel tfgatien, in My Stlielerrtieath ossumd at
<br />the time. date and place anddue to the ousels) sieed.43ignrduro abd.7aie).
<br />28a. HAS ORGAN OR E DONATION
<br />❑ YES ®NO
<br />26. DIDTOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES- ® NO 0 PROBABLY ❑ UNKNOWN
<br />27. N ME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />Odd. REGISTRAR'S SIGNATURE A- a,g"
<br />BEEN'CONSIDERED?
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 28e is NO n YES;
<br />28b. DATE FILED BY REGISTRAR
<br />July 28,:2015 ,
<br />
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