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To be completed by: CERTIFIER 1 1 To be completed /verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Cecil James Zornes Sr 2. SEX ' Male' '3 DATE tF DEATH (Ma., Day, Yr.) October 18, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Aurora, Nebraska 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH_(Mo., Day, Yr.) January 6, 1929 (Yrs.) 86 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -26 -1199 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) Golden LivingCenter -Grand Island Lakeview 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 1405 West Hwy 34 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 Eileen Frances Feddersen 11. FATHER'S -NAME (First, Middle, Last, Suffix) Elza Zornes 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Aida Thomas 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 11/10/1948- 06/09/1952 14a. INFORMANT -NAME Eileen Frances Zornes 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Katie M. Smydra 16b. LICENSE NO. 1454 16c. DATE (Mo., Day, Yr.) October 26, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY 1 TOWN STATE Westlawn Cemetery Grand Island 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 1. 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 if necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final a) Dementia Years disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: i i onset to death Sequentially list conditions, it b) 1 1 any, leading to the cause listed 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) I t (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 t 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ID 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 t ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH ® 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 221. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE a W 3 F Eti EI 23a. DATE OF DEATH (Mo., Day, Yr.) October 18, 2015 z w .t s LI i E Y oa.eX o w z 2 C O ~ u o 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) October 19, 2015 23c. TIME OF DEATH 10:25 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD 0 < 0 23d. To the best of my knowledge, death occurred at the time, date and place c- and due to the causa(s) stated. (Signature and Title) 2 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 Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR ❑ YES TISSUE DONATION BEEN CONSIDERED? El NO 26b. WAS CONSENT GRANTED? Not Applicabte if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE A D ADDRESS OF CERTIFIER (Type or Print Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 REGISTRAR'S SIGNATURE % / 12 t tr/`T�v 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 20, 2015 I 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 NEBRASJEA"DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR.- VITALiRECORDS. DATE OF ISSUANCE 10/23/2015 STATE OF NEBRASKA 201507722 STANLEY S. COOPER ASSISTANT STATE REGISTRAP, DEPARTMENT OF HEALTH ANQ LINCOLN, NEBRASKA HUMAN SERVICES - STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN Sp CERTIFICATE OF DEATH 15,06073