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DATE OF ISSUANCE STATE OF 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 I/.I,T34C�iRPS. 201503346 rAniL Ys. coOPEk .. . ASSISTANT $TATS REGISTFIAR DEPART NT OF HEALTH -APip LINCOLN, NEBRASKA 'HUMAN j ERV,1E STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 05/11/2015 15 02713 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Harold Elmer Bilslend 2. SEX -` l % i A - Male , 4 : DATA - 6F DEATH (Mo., Day, Yr.) April 29, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Kaw City, Oklahoma 5a. AGE - Last Birthday (Yrs.) 90 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) December 21, 1924 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -46 -1653 8b. FACILITY -NAME (If not Institution, give street and number) Golden Living Center -Cozad 8a. 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) Cozad 69130 8d. COUNTY OF DEATH Dawson 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Wood River 16600 West Burmood Road re. APT. NO. 9f. ZIP CODE I 68883 9g. INSIDE CITY LIMITS ❑ YES El 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 Patricia Felps 11. FATHER'S -NAME (First, Middle, Last, Suffix) Elmer Bilslend 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ethel Blackman 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Patricia Bilslend 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Bur lal ❑ Donation ❑ Cremation ❑Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Troy L. Tickle 16b. LICENSE NO. 1059 16c. DATE (Mo., Day, Yr.) May 2, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Wood River Cemetery Wood River 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) 16. PART I. Enter the chain of events - diseases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such es 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: onset to death IMMEDIATE CAUSE (Final a) Cardiopulmonary Arrest Minutes disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death Sequentially list conditions, if b) Coronary Artery Disease 1 Years any, leading to the cause listed t 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: I onset to death Enter the UNDERLYING CAUSE c) Hypertension 1 Years (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) i 1 18. PART 1I. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART I. PVD, CVA And Alchemies 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 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 ® 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. CITYITOWN STATE ZIP CODE A w F i v z 23a. DATE OF DEATH (Mo., Day, Yr.) April 29, 2015 a it cg I k Y a. 4 o w ` E p ~ 8 a 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) May 7, 2015 23c. TIME OF DEATH I 08:50 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD " ai 0 3 d. To the best of m knowled e, death occurred at the time, date and place Y 9 P o 8 and due to the cause(s) stated. (Signature and Title) f Stephen Nemeth, 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 265. 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 Stephen Nemeth, MD, 1803 Papio Lane, Cozad, Nebraska, 69130 r 1 28a. REGISTRAR'S SIGNATURE � � __ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) May 8, 2015 DATE OF ISSUANCE STATE OF 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 I/.I,T34C�iRPS. 201503346 rAniL Ys. coOPEk .. . ASSISTANT $TATS REGISTFIAR DEPART NT OF HEALTH -APip LINCOLN, NEBRASKA 'HUMAN j ERV,1E STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 05/11/2015 15 02713