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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE 05/19/2010 ~TM"LEY~5.,COQPER 201004599 ASSISTANT ,STATE' REGISTRAR ()~PARTMENT 6IEALTH'AND LINCOLN, NEBRASKA MUMAN &ER,VIC 5,,, STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HLIMAN:SEF VICES 1001376 CERTIFICATE OF DEATH r ! , 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) SFtx 3.,DATE OF DEATH (Mo., Day, Yr.) James Douglas Hollowell h/ISIe ° May 15, 2010 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday b. UNDER 1 YEAR 1~04110jKJ DAN 8. GATE OF BIRTH (Mo., Day, Yr.) (Yrs.) Mo$. DAYS ' HOURS , `1', y t~ Grand Island, Nebraska 57 June 28, 1952 7. SOCIAL SECURITY NUMBER 8a, PLACE OF DEATH 506-68-1573 HOSPITAL ❑ Inpatient OTHER © Nursing Home/LTC ❑ Hospice Facility Bb, FACILITY-NAME (If not institution, give street and number) ❑ ER/Outpatient ❑ Decedent's Home tY Five Points ❑ DOA ® Other (Specify ~Sk~gway North Rarking_Lot. `u 8c, CITY OR TOWN OF DEATH (include Zip Code) 8d. COUNTY OF DEATH o Grand Island 68801 Hall Q 9a. RESIDENCE-STATE 9b. COUNTY 8c. CITY OR TOWN ujw Nebraska Hall Grand Island Bd. STREET AND NUMBER 8e. AHT. NO. W, ZIP CODE 9g. INSIDE CITY LIMITS 1116 South Greenwich 68801 ® Yes ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH [@ Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name m !r_ ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown `m Mary Russell 11. FATHER'$•NAME (First, Middle, Last, Suffix) 12, MOTHER'S-NAME (First, Middle, Maiden Surname) 2 John Hallowell Dorothy Niemoth 13, EVER IN U.S. ARMED FORCES? Give dates of service If Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT E $ (Yes, No, or Unit.) No Mary Hollowell Wife 2 15. METHOD OF DISPOSITION 111a. EMBALMERSIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) c ® Burial ❑ Donation Gerald Quandt 1143 May 19, 2010 ❑ Cremation ❑ Entombment 96d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE ❑ Removal ❑ Other (Specify) West Union Cemetery Sargent Nebraska 17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code Livingston-Sondermann Funeral Home, 601 N, Webb Road, Grand Island, Nebraska 68803 RUSE DEATR (See Instructions an examples) 18. PART I. Enter the chain of events--disease,, Injuries, or complications-that directly caused the death. Do NOT enter terminal event, such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final a) Congestive Heart Failure ; Immediate disease or Condition resulting - - _ _ ' In death) DUE To, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) Hypertension Gradual any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death enter the UNDERLYING CAUSE c) Diabetes ; Gradual (disease or Injury that Initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART 11. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? a. ® YES ❑ NO W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? LL ❑ Not pregnant within past year ® Natural ❑ Homicide ❑ Ddvedoperator U ❑ pregnant at time of death C] Accident ❑ Pending Investigation ❑ Passenger ❑ YES ® NO 7. Q Not pregnant, but pregnant within 42 days of death ❑ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE M ❑ Suicide ❑ Could not be determined TO COMPLETE CAUSE OF DEATH? v ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ other (specify) d ❑ Unknown if pregnant within the past year ❑ YES ❑ NO O 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF E INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify) 8 1 22d. INJURY AT WORK? 22a, DESCRIBE HOW INJURY OCCURRED 6 ~ ❑ YES ❑ NO 22f. LOCATION OF INJURY • STREET S NUMBER, APT.NO, CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) 24a, DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 9 .W . S ---May 17, 2010 Approx. 09:15 PM 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d, TIME PRONOUNCED DEAD E Zaz May 15 2010 10:10 PM S O 3d. To the best of my knowledge, death occurred at the time, date and place w C 246. On the basis of examination and/or Investigation. In my opinion death occurred at c and due to the ca sets) stated. (Signature and Title) $ Q p the time, data and place and due to the causs(s) stated. (Signature and Title) S OIs Aaron Kunz, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN ❑ YES ® NO Not Applicable If 26a is NO ❑ YES ❑ NO 27. NAME, TITLE D CORONFK'3 PHYSICIAN OR COUNT-Y ATTORNEY) (Type or riot Aaron Kunz, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) May 19, 2010