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To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Lyle Junior Petsch 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) March 24, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Wauneta, Nebraska 5a. AGE - Last Birthday (Yrs.) 89 Sb. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) October 5, 1922 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -46 -9339 sb. FACILITY -NAME (If not Institution, give street and number) Wedgewood Care Center Ba. 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 800 Stoeger Drive 9e. APT. NO. 9f. ZIP CODE 68803 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 Virginia Loree Hrouda 11. FATHER'S -NAME (First, Middle, Last, Suffix) Fred William Petsch 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mabel Parson 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Virginia Loree Petsch 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Kevin Wood 16b. LICENSE NO. 1325 16c. DATE (Mo., Day, Yr.) March 29, 2012 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Memorial Park Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livingston - Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 17b. Zip Code 68803 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER I 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 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) Dementia disease or condition resulting onset to death 3 Years in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b) 1 any, leading to the cause listed I 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE C) t (disease or injury that initiated . the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LAST d) I 1 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART I. Coronary Artery Disease 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: 0 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 OF DEATH ® Natural a Homicide 0 Accident 0 Pending Investigation ❑ suicide ❑ could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES IX' 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 a W i re r E c z 23a. DATE OF DEATH (Mo., Day, Yr.) March 24, 2012 z �' ? g a k r E a a i O w z 0 z p ~ 0 S 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) March 27, 2012 23c. TIME OF DEATH 10:05 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD o 0 3d. To the best of my knowledge, death occurred at the time, date and place . a 2 o and due to the cause(s) stated. (Signature and Title) o David R. Colan, 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 ® NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print David R. Colan, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 1285. REGISTRAR'S SIGNATURE A - (�_7it7Jl)�f/V 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) March 28, 2012 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 DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. 4. 61* 0 1 4 '0 '3 ! STANLEY S. COOPER ASSISTANT SATE RE STRAR DEPARTMf IIT O FHEAL7 l AND HUMAN SERVICES DATE OF ISSUANCE 07/10/2014 LINCOLN, NEBRASKA STATE OF NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 12 01106