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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Jack Leslie Mattson 2. SEX Male .. 3. DATE OF DEATH (Mo., Day, Yr.) December 3, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Dunning, Nebraska 5a. AGE - Last Birthday (Yrs.) 73 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) April 3, 1941 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -46 -5995 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health Nebraska Heart 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) Lincoln 68526 8d. COUNTY OF DEATH Lancaster 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 223 E. 20th St. e. APT. NO. r 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS 0 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 Dorothy Jeanne Mattson 11. FATHER'S -NAME (First, Middle, Last, Suffix) Unknown Mattson 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Etta Mae Gould 13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Jeanne Mattson 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) December 8, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING 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) 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, r APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Eller only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting onset to death 6 Hours in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b)Acute Lung Damage 3 Days any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Re -do Aortic Valve Replacement 5 Days (disease or injury that initiated the events resulting in death( DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) 1 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, Chronic Obstructive Pulmonary Disease, Obesity, Diabetes. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnent 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 it pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide 0 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. CITY/TOWN STATE ZIP CODE 2' 5 i i i r E la z 23a. DATE OF DEATH (Mo., Day, Yr.) December 3, 2014 E g i E k Y S a. a z u W Z O 2 0 u ~ § S 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) December 5, 2014 23c. TIME OF DEATH I 02:23 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3d. To the best of my knowledge, death occurred at the time, date and plate o w and due to the cause(s) stated. (Signature and Title) m Sagar S. Damle, 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? 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 OF CERTIFIER (Type or Print Sagar S. Damle, MD, 7440 S 91st St, Lincoln, Nebraska, 68526 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 8, 2014 C 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 VITAL-RECORDS. DATE OF ISSUANCE 12/10/2014 201505298 STANLEY S= COOPER '• A$SISTANT,ST,�4TF REGISTRAR DEPARYMENrCf iigALT,H AND LINCOLN, NEBRASKA 11UMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SEI VIGE4- CERTIFICATE OF DEATH `. 14 06267