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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND. ryuMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA,E 'AR,T,MFIVT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY F6Ry1tk, 0CbRdS s I fi~ r: DATE OF ISSUANCE 201207575 . 01/31/2012 S-rANLEY9. OP ER r`AiSIST,4kr STATE REQ.5'TRAR "flPAF~TMr°NT1 C3F HFrAL H `AISID LINCOLN, NEBRASKA HUMAN SERVICES',: STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICE,' ry'~r 72 0279 CERTIFICATE OF DEATH 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SE7C' D;ATEOF'DEATH (Mo., Day, Yr.) Lester Robert Lentz Jr Male January 25, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday . UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.) (Yrs.) MOS. DAYS HOURS . MWS. Aurora, Nebraska 79 December 17, 1932 7. SOCIAL SECURITY NUMBER Be. PLACE OF DEATH 508-32-8781 HOSPITAL ® Inpatient OTHER ❑ Nursing Home1LTC ❑ Hospice Facility 8b, FACILITY-NAME (if not Institution, give street and number) ❑ EWOutpatlard ❑ Decedent's Home cc Saint Francis Medical Center ❑ ODA ❑ other (Specify) Sc CITY OR TOWN OF DEATH (Include Zip Code) Bd. COUNTY OF DEATH o Grand Island 68803 Hall 9a, RESIDENCE-STATE 9b. COUNTY Sc. CITY OR TOWN z Nebraska Hall Grand Island M 9d. STREET AND NUMBER 9a. APT. NO. 9f. ZIP CODE 9g. INSIDE CITY LIMITS 1831 West 10th St. 68803 ® YES ❑ NO y 106. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Mauled 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give malden name m ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Jeanette F McConnell 11i FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Maiden Surname) m *Lester Robert Lentz Sr Minnie G Rains E E 131 EVER IN U.S. ARMED FORCES? Give dates of service If Yes. 140. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT 8 '(Yea, No, or unit.) Yes 03/11/1953-03/10/1955 Jeanette F Lentz . Wife ,2 1S: METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE 18b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) F Burial ❑ Donation Tracey Dietz 1328 January 30, 2012 Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16d CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 170. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801 CAUSE OF DEATH See Instructions and examples) is. PART I. Enter the chain of eveMe-dlsmso% injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, ;APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrUlatiori without showing the etiology. DO NOT ABBREVIATE. Enter only one muse on a tine. Add additional lines D necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAM (Final a) Respiratory Failure ; 48 Hours disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death sequemaay list eanditlons. If b) Pulmonary Embolism ; 48 Hours any, leading to the muse Itsted orl Ilna a DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE O) Nonsmall cell Lung Cancer E 3 Months (disease or injury that Intuated Me resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death 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 Obstructive Lung Disease,pneurnonectorny,pneumonia OR CORONER CONTACTED? ❑ YES ® NO W LL. 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? g ❑ Not pregnant within past year ® Natural ❑ Homicide ❑ Driver/Operator YES NO ❑ ® W Pregnant at time of death ❑ Accident ❑ Pending investigation ❑ Passenger ❑ Not pregnaM, but pregrt M within 42 days of death ❑ Suicide ❑ could not be deremdrred ❑ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE © Not pregnant, but pmgnaM 43 days to 1 year before death ❑ Other (stay) TO COMPLETE CAUSE OF DEATH? Unknown H pregnant within the poet 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) 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED f° ❑ YES ❑ NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) .S January 25, 2012 A 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (M., Day, Yr.) 23c. TIME OF DEATH ro k 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD Z Janus 26, 2012 12:20 PM go. a 0 nJ $ O . To the best of my knowledge, death occurred at lire time, data and plain d $ 0 8 & 249. On the basis of examination and/or Investigation. in ray opinion death occurred at an due to tin muse(s) stated. (Signature and Title) ~ . p the lima, date and place and due to the muse(s) stated. (Signature and Title) Ryan D. Crouch, DO 3 8 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 H 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (P SICIAN, PHYSICIAN ASSISTANT, CORONERS PHYSICIAN A ORNIM (Type or nt) Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) - January 30, 2012