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STATE OF NEBRASKA
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<br />)M1FI'�EN" THIS;;:':;: COPY CARRIES THE RAISED .:.::. EA OF,z, :THE _STATE OF NEBRASKA; :
<br /><;:':CERTIFJFS = ;THE DOCUMENT BELOW TO BE< ' A `TRUE 'i OP ': `OF THE ORIGINAL. RE CiJ
<br />ON FILE WiTH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />.. RECORDS:OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR;;VRAL::RECORDS ,e+)�
<br />D.4 E OF ►SS1IANCE
<br />7/12/2O19
<br />LUNCOLN NFB:RASKA
<br />2 0 2 5 U5 2 8.' ...A:SSISTUSSELL FOSLER
<br />ANT STATE REGISTRAR'
<br />DEPARTMENT OF WEALTH
<br />. AND HUMAN SERVICES
<br />STATE OF NE, BRASKA - DEPARTMENT F1EAt:T . !AND HUMAN SERVICES
<br />CERTIFICATE OF DE:ATH::
<br />1. DECEDENTS -NAME '(First, MIdd L Last, Suffix)
<br />Earl Howard Tibbs
<br />At D:.STATE OR:TERRITORY. OR FOREIGN COUNTRY OF BIRTH
<br />artd'slart% Nirraska
<br />7. SOCIAL SECURITY NUMBER
<br />508-48-2067
<br />att. FACf.fl •NAME (OO'.no*lnstit
<br />CHI Health ::St. :Francis
<br />. CITY OR TOWN OF DEA1
<br />Grand Island 68803
<br />9.k RE$$DENCE=STATE:
<br />Nebraska
<br />9d. STREET. AND' NUMBER
<br />820 S Arthur St
<br />Inds Ziq 0
<br />and number)
<br />9b. COUNTY
<br />Hall
<br />.70p. MARITAL STATUS AT Tim OF DEATH ® MaMed 0 Never Married
<br />�� eta e' '. Bowe © rrlsd, bui Peratted m d 0 Divorced 0 Unknown
<br />FA HENt-NAME ".(First; Middle, Last, Suffix)
<br />Howard Earl Tibbs
<br />VE.RIN t S..ARMED..FORCEST Give dates Of service if Yes.
<br />as, No, ur Oki) Y/ 1 Yes 09 04t 959-06/191'1981
<br />Ili. METH4"SS?Ot455p.O$moN
<br />' 0 Burial` Detiation
<br />0 Cremation 0 Entombment
<br />• :0 Ret oxsl (0 gglOf tsPeclry)
<br />so 4og-t.astsirlhday;,
<br />7::'''
<br />5ti. UNDER.1 YEAR
<br />M
<br />DAYS
<br />ea. PLACE OF DEATH
<br />HOSPITAL jig Inpatient
<br />Elutpatient
<br />0 DOA
<br />9a,G1..ORTOV N
<br />Grand Island
<br />2. SEX
<br />Male
<br />3. DAYE OF D
<br />June 25;
<br />6c. UNDER 1 DAY
<br />HOURS
<br />9e. APT. NO.
<br />1Qb, NAME,QF SPOUSE:;(Firet,:;;;::Middle, Laic,
<br />Marlene':: bbs
<br />MINS.
<br />9f. ZIP CODE
<br />88803
<br />12. MOTHER'S -NAME (First, Middle,
<br />Eulalia Mary Bigley
<br />14a. INFORMANT -NAME ..
<br />Marlene A Tibbs
<br />16a. EMBALMER -SIGNATURE
<br />Benjamin Halt
<br />Ted. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Nebraska Anatomical Board � ' :
<br />1,:,:LICENSE NO.
<br />1305
<br />d Fi1MERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) ;' °'.:' ..
<br />Liu"inaston-Sonderrriann Funeral Home. 601 N. Webb Road, Grand island. Nebraska
<br />CITY' / TOWN
<br />Omaha
<br />CAUSE OF DEATH (See instructions and examples)
<br />14b RELA1tf t$ti(P:?Q DEt DINT::.
<br />8.04 FT:L EON i eArlairtet events•-diseiast. Injurer% or compiicationsXMt directly uulittl thb deialhDO NDTent !f:[Mfiinid bastes such as cardiac srmst,
<br />i*spkatoey"aeiewot.veiitrf user IWrUknion whhot*showing the etiology. DO NOT ABBREVIATE. F41dar only :One: airee en s Hrwy::lUid addRkrnal lints lr nuesssary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE I.
<br />diausa er Condition MN/eft
<br />::>Ssiii utitltmf+ lie..;• c ^ptIR l(N
<br />'::any, f ef)inp to:t* cXiia lI* ere;
<br />Enter the UNDERLYING CAUSE
<br />Vilsi a:!ot:.hrJuNthetlniUltiW..':
<br />the *Yenta t'Mi!lti ;i _ ddlitll) '
<br />LAST:':
<br />a) Respiratory Failure
<br />DUE TO, OR AS A CONSEQUENCE OF.
<br />End Stage Chronic Obstructive Pulmonary 0i
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />e) Chronic Systolic Heart Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d►Hemolytic Anemia
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contdbudng to the death but not resulting in the underlying cause given in P
<br />„Patient.D.. ittSd.AndTransitlonedToComfortCaresAndPassedAway
<br />to. 1FFE.MAi E:.."
<br />0 Not praanaimwlti,lnpati r
<br />MgnaM at tint* of death
<br />,._:. Nat:prepnant;:bul pregnant yAt nin 42 days of death
<br />.�•�;i.Jut pri4o.ont....poi#401.0 43 days to T year before death
<br />Urlknioydilfpm dafifjditliin:thapastyear
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />fld INJuRYATWQRI+E?:::
<br />C7 sDio :.
<br />22b.
<br />21a. MANNER OF DEATH
<br />50 Natural Homicide .. .
<br />0 ACc1dere 0 Pending Inwratigation
<br />0 suicide 0:Could not be daNtmined
<br />E OF INJURY
<br />21htF:TRANSPORTATION INJURY
<br />.' ©'Driver/Operator
<br />0 Passangar
<br />Padsstn.n
<br />0tdartsp•ctry)
<br />T 1.
<br />21a. WAS AN A
<br />0 YES
<br />**ER
<br />RRM
<br />21d. WERE AUTOPSY_ PIHOI#+.i68AVA:1EABLE
<br />TO COMP3.E1'tc CAAUSE.OF
<br />22c. PLACE OF INJURY -At home, farm, street. factory, office bulldhp,
<br />IBE HOW INJURY OCCURRED
<br />22f. LOCATION OF f!IJURY . STREET a NU
<br />R,,APT.NO. CITY/TOWN
<br />i23ir&,DA':IE:OF::DFa ; i (Ma,, Day, Yr.)
<br />€>Jti:r>e; 2S#2�19
<br />;234: DA:':TE 81iEb (MO:; Day, Yr.) 23c. TIME OF DEAi H
<br />JiIIv 201s 11:45 PM
<br />ad. To the best of my mowerago. death occurred at ma Lana, date and ghee
<br />and due to me cause(a) stated (Signature and Tina)
<br />clsael AQanner, MD
<br />$E. optoB \CCO SEf `Of/TRIBUTE TO The DEATH?
<br />M YES [3 NO ` `0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORG
<br />❑ YES
<br />STATE
<br />SIGNED (Mo., Day, Yr.)
<br />UfICED DEAR(Mo., Day, Yr;
<br />onatnrcdon Oft, eta.(Speclry>
<br />24a. On the beefs of examinaden an(i/or Ineeedgaeon, feint aWNae dMgt eseitrred
<br />the tires, date and place and duet to the ctua(s) atitud. RtPM4lnianf 1I0e)
<br />OR TISSUE: DONATION
<br />Si NO ...
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />;; :Michael A:Ponner.;MD, 729 North Custer Avenue, Grand Island;,;Nebraska,.
<br />808.
<br />28b. DATE FILED BY
<br />July 10, 2019,
<br />
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