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STATE OF NEBRASKA 201204992 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' DFPAATlifiiVI7:OF"HF,ALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR MAC kFrOkps g', 7 ,000~ DATE OF ISSUANCE ' 03106/2012 ASSIST.ANT.SA+T ~IS~RA/2 D&A' 4MENT OF HEALTH AND LINCOLN, NEBRASKA HU*11 SERYJCES "s STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICFiS' -1200690 CERTIFICATE OF DEATH 1. DECEDENTS-NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.) Patrick Dale Langer Male February 27, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE -Last Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) (YB•) MOS. DAYS HOURS MIN S. Fort Carson, Colorado 39 December 24, 1972 7~ SOCIAL SECURITY NUMBER Be. PLACE OF DEATH 507-08-1631 HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility qb. FACILITY-NAME Of not Institution, give street and number) ❑ ERIOutpatient ❑ Decedent's Home v 19 Jansen ❑ DOA ® Other (Spectfy)Rural Howard County So. CITY OR TOWN OF DEATH (Include Zip Code) Oil. COUNTY OF DEATH C Near St. Paul 68873 Howard Sit. RESIDENCE-STATE 9b. COUNTY CITY OR TOWN - z Nebraska Hall Grand Island T 9d. STREET AND NUMBER 9e, APT. N0. 9f. ZIP CODE 8g. INSIDE CITY LIMITS 2208 Woodridge Ct. 68801 ® YES ❑ NO tbs. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) K wtie, give maiden name ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ unknown Carolyn Kathleen Langer 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname) m Patrick David Long Susan Mary Hartley c' E 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT 8 (Yea, No, or unit.) No Carolyn Kathleen Langer Wife .9 18. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) H ® Burial ❑ Donation Laurie D. Sheffield 1397 March 3, 2012 ❑ Cremation ❑ Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE ❑ Removal ❑ Other (Speccitfy) Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801 CAUSE OF DEATH See Instructions and examples) 14. PART 1. Enter the chain of events.-diseases, injurlm or complications that directly mused the death. 00 NOT ender terminal events such as cardlac arrest, : APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE Enter only one muse on a Una. Add additional lines If necessary. IMMEDIATE CAUSE: onset to death HWINIEDIATE CAUSE (Final a) Trauma To Head And Brain E Immediate disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: ( onset to death Sequentially list conditions, if b) Self Inflicted Gun Shot Immediate any, leading to the muse listed On Iirre a. DUE TO, OR AS A CONSEQUENCE OF: I onset to death Enter the UNDERLYING CAUSE G) (disease or Injury that Initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LAST 18. PART 11. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given in PART 1. 18. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO K w LL 0. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? ❑ Not pregnant within past year ❑ Natural ❑ Homicide ❑ Ddverlopendor ❑ YES [21 NO W Pregnant at time of death ❑ ❑ Accident ❑ Pending investigation Passenger V ❑ Not pregnant, but pregnant within 42 days of death Suicide Could not be detsmurhea ® ❑ Pedestrian ❑ 21d. WERE AUTOPSY FINDINGS AVAILABLE COMPLETE CAUSE OF DEATH? ❑ Not preeeant, but pregnant 43 days t01 year before death ❑ Other (Specxy) TO . ❑ Unknown if pregnant within the past year ❑ YES ❑ NO E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify) 3 February 27, 2012 09:30 AM Outside of A Lake home In Rural Howard County 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED F YES ®NO F_ Decedent shot himself In the head with a pistol. 22f. LOCATION OF INJURY-STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE 19 Jansen Circle, St. Paul Nebraska 68873 23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH N B I I February 29, 2012 Approx. 09:30 AM I 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH B k 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD I o Y a c February 27, 2012 10:40 AM ed. To the hest of my knowledge, death occurred at the time, data and place s z 240. On the basis of euantlnatlon and/or investigation, in rtry opinion death occurred at Si d Tal and due to the muse(s) stated. (Signature and This) g gnature an e) the time, data and place and due to the muse(s) stated. ( I. David T. Schroeder, Howard 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. NAMF~ TITLE D ADDRESS OF CER IFIER (PHYSIC PHYSICIAN ASSISTANT, OR ER'S PHYSICIAN R COUNTY ATTORNEY) (Type or Print) David T. Schroeder, Howard County Attorney, 612 Indian St., Ste 3, St. Paul, Nebraska, 68873 28a. REGISTRAR'S SIGNATURE ~ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) - ~ February 29, 2012