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To be completed /verified by: FUNERAL DIRECTOR I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) .;,,; Edward Raymond Ziska 2. SEX - - • • • Mal@ $ ' '1I.-`! " a. D'ATOF DEATH (Mo., Day, Yr.) . 1 A6gust-11, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Atkinson, Nebraska 5a. AGE - Last Birthday (Yrs.) 80 5b. UNDER 1 YEAR 5c. UNDER I'DAY,, ,, & DA1' O F BIRTH (M&., Day, Yr.) ;.August 27, 1934 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508-42 -1588 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 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) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 403 E. 18th 9e. APT. NO. 9f. ZIP CODE 68801 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 Charlene M Campbell 11. FATHER'S -NAME (First, Middle, Last, Suffix) James E Ziska 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Teresa H Athe 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 04/17/1957- 03/27/1959 14a. INFORMANT -NAME Charlene M Ziska 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Chris McCoy 16b. LICENSE NO. 1191 16c. DATE (Mo., Day, Yr.) August 14, 2015 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) To be completed by: CERTIFIER I 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 1 Week 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: IMMEDIATE CAUSE (Final a) Pneumonia disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b)Chronic Obstructive Pulmonary Disease With Hypoxemia 1 1 Year any, leading to the cause listed I 1 on line a . DUE TO, OR AS A CONSEQUENCE OF: r onset to death Enter the UNDERLYING CAUSE c) Metastatic Carcinoma Pancreas 1 20 Months (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 I I . OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the . . .t o t death resulting in the underlying cause given in PART I. Depression 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 2. 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 ❑ Pe Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ DriverlOperator ❑ 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? DYES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET S NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) August 11, 2015 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) August 12, 2015 23c. TIME OF DEATH 07:55 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) William Landis, 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 26a. HAS ORGAN OR ❑ YES DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print William Landis, MD, 2444 W. Faidley Avenue, Grand Island, Neb - • 03 r 1 28a. REGISTRAR'S SIGNATURE /� I I� a {•IOp��V 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I August 13, 2015 DATE OF ISSUANCE 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 NEBRASKAQEM4 ENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITA R STANLEY'S . OOPER`~ • ASSISTANT . 'rATEREGI$TRA,o, DEPARTS ORH LTH:AND, Hf&NMAN Vd,F STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SEVICES, ; A CERTIFICATE OF DEATH C " . 08/18/2015 LINCOLN, NEBRASKA STATE OF NEBRASKA 15 04719