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DATE OF ISSUANCE 04/29/201 LINCOLN, NEB STATE OF NEBRASKA LIMN WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND N SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKIWYE1�ARTME!JrOF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSIT9RY FOR VITAL RECORDS. ' 'STANLEY S COOPER • 3 ASSISTANT STATE REGISTRAR : ^ D&,PARTMENT OF HEALTH HM;AN SERVICES • • STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMSERVlcE8' • r ' )` 13 01856 CERTIFICATE OF DEATH _ es i, 1. DECEDENTS-NAME (First, Middle, Last, Suffix) David Michael Citta Sr 2. SEX Mare, 3 DATE,OFDEA'TU(Nto., Day, Yr.) „ 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Omaha, Nebraska 5a. AGE - Last Birthday (Yrs.) 58 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 'E DATE DF BIRTH (Mo., Day, Yr.) July 5, 1954 MOS. DAYS HOURS' MI NS. v 7. SOCIAL SECURITY NUMBER 506 -76 -9089 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatlent ❑ 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 4146 Manchester Road e. APT. NO. r 8f. ZIP CODE I 68803 9g. INSIDE CITY LIMITS O 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) If wife, give maiden name Wendy Lynn Bell 11. FATHER'S -NAME (First, Middle, Last, Suffix) Joseph Louis Citta Sr 12. MOTHER'S -NAME (First, Middle, Maiden Sumame) Marjorie Ann Dose 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Wendy Lynn Citta 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Daniel D Naranjo 16b. LICENSE NO. 1071 16c. DATE (Mo., Day, Yr.) April 27, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn - Hillcrest Cemetery Omaha Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART I. 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 Hours respiratory arrest, or ventricular fibrillation 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) Anoxic Multi system Organ Failure disease or condldon resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Ventricular Fibrillation Hours any, leading to the cause listed on line 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 DF: onset to death LAST d) 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contrIguting Acute Myocardial Infarction, CAD, Carotid Artery Stenosis, Nocturnal to the death but not resulting In the underlying cause given in PART I. Hypoxemia, Syncope, Hypertension, 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 0 N 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 within the past year 21a. MANNER ® Na ❑ Ac OF DEATH ral ❑ Homicide ident o Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator Passenger ❑ ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO ❑ Suicide ❑ Could not be determined 21 d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 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? ❑YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE B W Y E' 23a. DATE OF DEATH (Mo., Day, Yr.) April 23, 2013 21 i 2 i k Y g N< g s w _, 2 ig 5 ' 0 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) April 23, 2013 23c. TIME OF DEATH I 01:00 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3 Y 3d. To the hest of my knowledge, death occurred at the time, date and place 2 and due to the cause(s) stated. (Signature and Title) s Kimberly A. Mickels, 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 TISSUE DONATION BEEN CONSIDERED? ❑ YES ONO 26b. WAS CONSENT GRANTED'? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE `/� -�„ - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I April 29, 2013 DATE OF ISSUANCE 04/29/201 LINCOLN, NEB STATE OF NEBRASKA LIMN WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND N SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKIWYE1�ARTME!JrOF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSIT9RY FOR VITAL RECORDS. ' 'STANLEY S COOPER • 3 ASSISTANT STATE REGISTRAR : ^ D&,PARTMENT OF HEALTH HM;AN SERVICES • • STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMSERVlcE8' • r ' )` 13 01856 CERTIFICATE OF DEATH _ es i,