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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) LeRoy Charles Kraft 2. SEX ` € Male 3. DATE OF DEATH (Mo., Day, Yr.) : August 8, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Albion, Nebraska 5a. AGE • Last Birthday (Yrs.) 79 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) December 23, 1932 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506-40 -0297 8b. FACILITY -NAME (H not Institution, give street and number) Saint Francis Medical Center 8a. PLACE OF DEATH HOSPITAL ® inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER re. APT. NO. 16 Kuester Lake 9f. ZIP CODE I 68801 9g. INSIDE CITY LIMITS ❑ YES ® NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) H wife, give maiden name Rita Marie Rueth 11. FATHER'S -NAME (First, Middle, Last, Suffix) Philip Kraft 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Grace Fisher 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Rita Marie Kraft 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal 0 Other (specify) 16a. EMBALMER-SIGNATURE Derek Apfel 16b. LICENSE NO. 1240 16c. DATE (Mo., Day, Yr.) August 13, 2012 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER I 18. PART 1. Enter the chain of events-diseases, Injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest. APPROXIMATE INTERVAL onset to death One Week respiratory arrest, or ventricular flbdllatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Acute Pancreatitis disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) any, leading to Me cause listed on IMe a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (disease or Injury that Initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART I. Chronic Obstructive Pulmonary Disease 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant wlthln the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ID NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, fans, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE b' a Y E EI 23a. DATE OF DEATH (Mo., Day, Yr.) August 8, 2012 .2 1 < $ 8 W z G ~ 1 t 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) August 9, 2012 23c. TIME OF DEATH I 06:44 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD E g 0 9d. To the beat of my knowledge, death occurred at the time, date and place and due to Inc cause(s) stated. (Signature and Title) W Donald Wirth, MD 24e. On the basis of examination and/or investigation, In my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR ❑ YES ISSUE DONATION BEEN CONSIDERED? /:1 NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES ❑ NO I) I 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Donald Wirth, MD, 2116 W Faidley #400, Box 9802, Grand Island Nebraska, 68803 28a. REGISTRAR'S SIGNATURE f j) /r � � A 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I August 14, 2012 DATE OF ISSUANCE 08/16/2012 LINCOLN, NEBRASKA STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF'THE NEBRASKA DEPARTMENT OF HEALTH "FMOIN141 THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA,ifA D$PAWtME(VT HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR , yITAC 12ECQ 2QS: Or. \ t 201210151 #A� SDANLEY S PE ,z ,,, f ASSFSTAN T E gsrkafvf,:::t.', D$P, RTNPE 1 � AW¢= ,, HwMAIy'SE8VICES ;:+.'' -',. ,�,' CERTIFICATE OF DEATH i • ' ' , , . . , R'VICES IT CERTIFIES 11-1EALTH AND ) 6 1 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES* < ,,r • [ ( * 12 02931 •