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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Alvin D Panker 2. S& ' Male i ,< < 1 3: DATE OF DEATH (Mo., Day, Yr.) , . September 24, 2011 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Hastings, Nebraska 5a. AGE • Last Birthday (Yrs.) 82 5b. UNDER 1 YEAR 5c. UNDER 1 DAY, DATE OF BIRTH (Mo., Day, Yr.) February 2, 1929 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -28 -1588 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER El Nursing Home /LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Lakeview -A Golden Living Center ❑ 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 Doniphan 9d. STREET AND NUMBER 204 E Pine Street 9e. APT. NO. I 9f. ZIP CODE I 68832 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 Kathryn Hegwood 11. FATHER'S -NAME (First, Middle, Last, Suffix) Alvin L Panker 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mabel Ralstin 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes Dates Unknown 14a. INFORMANT -NAME Kathryn Panker 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMERSIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) September 27, 2011 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE BV Cremation Center Hastings Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livingston - Butler - Volland Funeral Home, 1225 N. Elm, Hastings, Nebraska 17b. Zip Code 68901 I CAUSE OF DEATH (See instructions and examples) I 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 10 Years respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a 11110. Add additional lines If necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Chronic Obstructive Pulmonary Disease disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) any, leading to the cause listed on 11110 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 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting In the underlying cause given in PART 1. Coronary Artery Disease, Atrial Fibrillation 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El 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 within the past year 21a. MANNER OF DEATH El 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 W E. i Y E 0 E 23a. DATE OF DEATH (Mo., Day, Yr.) September 24, 2011 .t g i 1 g T E < 8 W z 8 C § .- g s 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) September 27, 2011 23c. TIME OF DEATH 02:04 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 13 g 0 3d. To the best of my knowledge, death occurred at the time, date and place 8 a and due to the cause(s) stated. (Signature nd Title) W David R. Colan, MD 24e. On the basis of examination and /or invastig tion, 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 El 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 28a. REGISTRAR'S SIGNATURE �� y " � � w � W I 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) September 27, 2011 I STATE OF NEBRASKA DATE OF ISSUANCE �) / 06/09/2014 0 6 � / a o LINCOLN, 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 DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS: STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SF,R1dfc'ES CERTIFICATE OF DEATH • STA S COOPER" ' ASSISTANT STATE REGISTRAR'. DEPARTMENT OF HEALTH AND HUMAN SERVICES' 11 03163