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To be completed by: CERTIFIER 1 1 To be completed/verified by: FUNERAL DIRECTOR 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Bernard Louis Chrapkowski 2. SEX ' i ..'• .. J Male " -: 3: DATEOF - DEATH (Mo., Day, Yr.) • February 9, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Loup City, Nebraska 5a. AGE • Last Birthday 5b. UNDER 1 YEAR 5c. UNDER`1 6. DATE OF BIRTH (Mo., Day, Yr.) (Yrs.) 80 MOS. I DAYS HOURS MINS. July 25, 1934 7. SOCIAL SECURITY NUMBER 507 -36 -1989 8a. PLACE OF DEATH HOSPITAL, ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/outpatient ® Decedent's Home ❑ DOA ❑ Other (Specify) 8b. FACILITY -NAME (If not Institution, give street and number) 120 W. 20th Street 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 120 W. 20th Street 9e. APT. NO. 9f. ZIP CODE 68801 I 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 Shirley Ann Bruntz 11. FATHER'S -NAME (First, Middle, Last, Suffix) Ferdinand Chrapkowski 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Sophia Bozman 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Shirley Ann Chrapkowski 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Not Embalmed 16h. LICENSE NO. 16c. DATE (Mo., Day, Yr.) February 12, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon 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 DEATH (See instructions and examples) 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 N necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final a) Lung Cancer 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 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: 1 onset to death LAST I d) 1 I 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Chronic Obstructive Pulmonary Disease 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ 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 ❑ P ending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 0 N 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 3 i F ri ; 23a. DATE OF DEATH (Mo., Day, Yr.) 0 B s z Y E p Y 1 W 2 P. u a 2 DATE SIGNED (Mo., Day, Yr.) February 12, 2015 24b. TIME OF DEATH 03:45 PM 23b. DATE SIGNED (Mo., Day, Yr.) 123c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) February 9, 2015 24d. TIME PRONOUNCED DEAD 04:00 PM E � a 0 23d. To the best of my knowledge, death occurred at the time, date and place 5 o and due to the cause(s) stated. (Signature and Title) f 248. On the balls 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) Dave Medlin, 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 Dave Medlin, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 128a, REGISTRAR'S SIGNATURE (� A- /a 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) February 12, 2015 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND.H(A1k_SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKAQEAA$V EN'"t)F`HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITdt rfRRiAN DATE OF ISSUANCE 02/17/201 LINCOLN, NEB RASKA . - 20 5"139 "SA STArf E r rt . PART T11.AND STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN4EfAf3, CERTIFICATE O DEATH 15 00840