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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Lawrence Thomas Kapustka 2 SEX - ` / + Male • • 3: DATEOF DEATH (Mo., Day, Yr.) °F -March 27, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Ewing, Nebraska 5a. AGE - Last Birthday (Yrs.) 72 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) October 6, 1941 MOS. DAYS HOURS MINS. 7. SOCIAL. SECURITY NUMBER 506 -46 -7308 8b. FACILITY -NAME (If not Institution, give street and number) 2120 Viking Road 8a. PLACE OF DEATH HOSPITAL 0 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 8a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2120 Viking Road APT. NO. 81. ZIP CODE 68803 8g. 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 Leslie Hanson 11. FATHER'S -NAME (First, Middle, Last, Suffix) Raymond Kapustka 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mary Leahy 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Link.) Yes 09/10/1959- 11/04/1960 14a. INFORMANT -NAME Leslie Kapustka 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Chris McCoy 16b. LICENSE NO. 1191 16c. DATE (Mo., Day, Yr.) March 31, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon 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 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 Immediate respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. EMer only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Cardiac Arrest disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Bladder Cancer Gradual 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 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. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? O YES ❑ NO 20. IF FEMALE: ❑ Not pregnant within past year 0 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 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 construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE S W I >- 1 23a. DATE OF DEATH (Mo., Day, Yr.) a a § = G ,- I a. < i'ro 8 W 8 € p ' 0 3 24a. DATE SIGNED (Mo., Day, Yr.) March 28, 2014 24b. TIME OF DEATH Approx. 04:00 AM 23b. DATE SIGNED (Mo., Day, Yr.) 1 23c. TIME OF DEATH 24c PRONOUNCED DEAD (Mo., Day, Yr.) March 27,2014 24d. TIME PRONOUNCED DEAD 07:35 AM O 9d. To the best of my knowledge, death occurred at the time, date and place 8 a and due to the cause(,) stated. (Signature and Title) 1 L i' 24e. On the basis of examination and /or Investigation, In my opinion death occuned at the time, date and place and due to the cause(s) stated. (Signature and Title) Martin Klein, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Martin Klein, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 128a . REGISTRAR'S SIGNATURE /7 _ 28b. DATE FILED BY REGISTRAR (nto., Day, Yr.) April 1, 2014 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HFA.TH+ANQ SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEB'RAgKA pEPRR77h4ENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY` POR'VITAL.RECORDS; L DATE OF ISSUANCE 201 /4 a 2 1 ' U S TANLEY . V 'T AS 7'A. ;PVT ST 4TE REGTS712AR DE *If 7 HEALT/I AND LINCOLN, NEBRASKA HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERV1OES , ' t'.' a , '` CERTIFICATE OF DEATH 04/02/2014 14 01501