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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Kenneth Lee Hoffman 2. SEX ' ( Male , 3. BATE OF DEATH (Mo., Day, Yr.) November 1o; 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Lincoln,- Nebraska 5a. AGE - Last Birthday (Yrs.) 71 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6 DATE'GFBIRTH (Mo., Day, Yr.) March 13, 1942 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -52 -6789 8b. FACILITY -NAME (If not Institution, give street and number) 1709 Allegheny Circle 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 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1709 Allegheny Circle e. APT. NO. r 9f. ZIP CODE 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) If wife, give maiden name Joyce Marie Chevalier 11. FATHER'S -NAME (First, Middle, Last, Suffix) Robert Hoffman 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mary Slote 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Joyce Marie Hoffman 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation [] Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) November 19, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEA'K(See instructions and examples) To be completed by: CERTIFIER 15. 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 Minutes 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) Myocardial Infarction disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b) Hypertension I any, leading to the cause listed 1 i line on e. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) 1 (disease or injury that Initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: , onset to death LAST d) 1 1 1 18 PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Diabetes, High Cholesterol, Prostate Disease 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO IF FEMALE: Not pregnant within past year Pregnant at time of death Not pregnant, but pregnant within 42 days of death J Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within 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 El NO 21d. 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 ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) a Y 1 E a. < ZZ ' ' y W z O g K § Schneider, 0 s 24a. DATE SIGNED (Mo., Day, Yr.) November 18, 2013 24b. TIME OF DEATH Approx. 12:20 AM 23b. DATE SIGNED (Mo., Day, Yr.) 123c. TIME OF DEATH' 24c. PRONOUNCED DEAD (Mo., Day, Yr.) November 15, 2013 24d. TIME PRONOUNCED DEAD 12:31 AM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) , On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the camels) stated. (Signature and Title) Nancy Berger- Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Nancy Berger- Schneider, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 128a. REGISTRAR'S SIGNATURE - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) November 19, 2013 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 121RTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIT.A't WORDS. DATE OF ISSUANCE 201309479 QPER, ASSISTANT SATE REGIS , Pe DEPARTMENT OF'HEALTH AND LINCOLN, NEBRASKA HUMAN SERVICES , STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES / �n 11/21/2013 CERTIFICATE OF DEATH 13 04961