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17. To be completed by: CERTIFIER I I To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Wayne Victor Pennell 2. SE(' . ` ' • M 3. DATE OF DEATH (Mo., Day, Yr.) October 21, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Trenton, Nebraska 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 8: tIATE OF BIRTH (Mo., Day, Yr.) December 1, 1931 (Yrs.) 83 MOS. DAYS HOURS MINS. SOCIAL SECURITY NUMBER 507 -36 -0059 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) Good Samaritan Society -Wood River 8c. CITY OR TOWN OF DEATH (Include Zip Code) Wood River 68883 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2020 N. Park Ave. 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Marred ❑ Married, but separated 0 Widowed ❑ Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Lois Regina Williams 11. FATHER'S -NAME (First, Middle, Last, Suffix) Fred Pennell 12. MOTHER'S -NAME (First, Middle, Maiden Sumame) Emma Dayton 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Lois Regina Pennell 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑Entombment ❑ Removal 0 Other (Specify) 16a. EMBALMER - SIGNATURE Katie M. Smydra 16b. LICENSE NO. 1454 16c. DATE (Mo., Day, Vr.) October 27, 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) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 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 Hours 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) Acute Myocardial Infarction disease or condition resulting n death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b) Diabetes Mellitus 1 any, leading to the cause listed i 1 on line a . DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) Alzheimers Dementia 1 (disease or injury that Initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: t onset to death LAST 1 d) 1 1 8. 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 ® NO 0. 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 ❑ Pending Investigation ❑ Suicide ❑ Ci 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 To be completed by l MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Dav,_Yr.) - Octobet21, 2015 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a..DATE S!GNEr! (Mo., Day, Yr.) 24b. TIME OF DEAN 23b. DATE SIGNED (Mo., Day, Yr.) October 23, 2015 23c. TIME OF DEATH 08:40 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Richard Fruehling, 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? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 128a, REGISTRAR'S SIGNATURE v I 1 __ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 27, 2015 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HU N SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR, SK b0kl E OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FQ$°VITI44., ) t DATE OF ISSUANCE ST: NLEY S- CD.OPER %` t ASSIST ,..,STATE REGI57 k4R DEPAR `T TH. I�EAL A LINCOLN, NEBRASKA H(JMAI Rt/fCeS ' STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER∎hDES r , r, 15 06207 10/30/2015 STATE OF NEBRASKA CERTIFICATE OF DEATH