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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SEfVIGES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DER.ARThIENT.OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL,R DATE OF ISSUANCE 201501266 Sw.d.. Y COQ A�SISTAN,T..r eLEFAR O M LINCOLN, NEBRASKA / HUMAN STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN .SERI (ICES CERTIFICATE OF DEATH , A '•' ✓ 11/03/2014 • c 4 05567 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Frank Clyde Patton 2. SEX '' P ' • 1 ,nd M t f j j *>'bATEOt bEMRl (Mo., Day, Yr.) / .Oefober9 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Long Island City, New York 5a. AGE - Last Birthday (Yrs.) 79 5b. UNDER 1 YEAR 5c. UNDER' fDlr . it DATE"OF BIRTH (Mo., Day, Yr.) `September 25, 1935 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -36 -6573 8a. PLACE OF DEATH HOSPITAL, ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Hamilton Manor ❑ ER/Outpatient ❑ Decedent's Home ,. ❑ DOA ❑ Other(Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Aurora 68818 8d. COUNTY OF DEATH Hamilton 9a. RESIDENCE -STATE •, Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2305 West John Street e. APT. NO. r 9f. ZIP CODE I 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 Kathy Grasmick 11. FATHER'S -NAME (First, Middle, Last, Suffix) Glen Patton 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ruth Voshell 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 10/05/1955- 09/20/1957 14a. INFORMANT -NAME Kathy Patton 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Tracey Dietz 16b. LICENSE NO. 1328 16c. DATE (Mo., Day, Yr.) October 27, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING 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) 14. PART 1. Enter the chain of events - diseases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death Years respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Alzheimers Dementia disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death Sequentially list conditions, if b) 1 any, leading to the cause listed I on line a. 1 DUE TO, OR AS A CONSEQUENCE OF: I 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: 1 onset to death LAST d) i I 1 18. PART II.OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Chronic Obstructive Pulmonary Disease 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 ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ID 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. CITY/TOWN STATE ZIP CODE .r 5 $ $ rc , m 1 23a. DATE OF DEATH (Mo., Day, Yr.) October 22, 2014 a 1 Z I g 1 ,. ° g ' W Z 2 2 C O 1 24a. DATE SIGNED (Mo., Day, Yr.) ` 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) October 29, 2014 23c. TIME OF DEATH I 11:12 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 4 O 3d. To the best of my knowledge, death occurred at the time, date and place g due to the cause(s) stated. (Signature and Title) o c f Travis S. Hageman, 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 causes) stated. (Signature and Tale) 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 ?CERTIFIER (Type or Print Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE ii - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 31, 2014 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SEfVIGES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DER.ARThIENT.OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL,R DATE OF ISSUANCE 201501266 Sw.d.. Y COQ A�SISTAN,T..r eLEFAR O M LINCOLN, NEBRASKA / HUMAN STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN .SERI (ICES CERTIFICATE OF DEATH , A '•' ✓ 11/03/2014 • c 4 05567