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To be completed/verified by: FUNERAL DIRECTOR f 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Henry Anton Polak 2. SEX 1'0- "".,DA7 Mate, • Op1=A'${1 Day, Yr.) June•3, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Valley County, Nebraska 5a. AGE - Last Birthday (Yrs.) 87 6b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) April 5, 1928 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -30 -8247 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 3946 Reuting Road 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS W 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 Maxine Mae Goehring 11. FATHER'S -NAME (First, Middle, Last, Suffix) Frank Polak 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Frances Lancova 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or link.) No 14a. INFORMANT -NAME Maxine Mae Polak 14b. RELATIONSHIP TO DECEDENT Spouse 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.) June 4, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY 1 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 U CAUSE OF DEATH (See instructions and examples) 1 To be completed by: CERTIFIER 16. PART!. 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. Enter only one cause on a line. Add additional lines B necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Acute On Chronic Heart Failure disease or condition resulting onset to death 3 Weeks In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Arteriosclerotic Cardiovascular Disease, Coronary Artery Disease 30 Years any, leading to the cause listed on fine a. DUE TO, OR AS A CONSEQUENCE OF: i onset to death Enter the UNDERLYING CAUSE c) Diabetes Mellitus,Type 2 1 Years (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST 1 d) 1 1 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death ' . of resulting in the underlying cause given in PART I. Chronic Renal Failure, Chronic Cerebralvascu(ar 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 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 131) NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES O 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 S" W F 23a. DATE OF DEATH (Mo., Day, Yr.) -' June3,2015 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.) June 4, 2015 23c. TIME OF DEATH 01:45 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 0 3d. To the best of my knowledge, death occurred at the time, date and place g and due to the cause(s) stated, (Signature and Title) 2 Steven Husen, 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 ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ISSUE s • ATION BEEN CONSIDERED? gl NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Islan , Nebraska, 68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) June 8, 2015 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 QEPAilli. T.h1ENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VZ194 RE '9RD DATE OF ISSUANCE 06/12/2015 LINCOLN, NEBRASKA STATE OF NEBRASKA :STjytI EY'S. COOPER' S " ` .SSISTANT STA71 REGIS,TRAP,. �•D; PART( I LT1 .w. A ; HUMAN STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN/SERyIEES,„ CERTIFICATE OF DEATH 201508227 15 03295