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STATE OF NEBRASKA t03 0 WHEN THIS ' COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT 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 03/07/2016 LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Frank B Pesek Jr 4, CITY AN STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Comstock, Nebraska 7, SOCIAL SECURITY NUMBER 507 -48 -4723 $b. 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 9a, RESIDENCE- STATE Nebraska 9d. STREET AND NUMBER 2508 W 1st Street 11. FATHER'S -NAME (First, Middle, Last, Suffix) Frank Pesek 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No or Unk.) Yes Unknown- 03/28/1954 15. METHOD OF DISPOSITION ❑ Burial El Donation ❑ Cremation ❑ Entombment ❑ Removal ; Other (Specify) 7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Mid America First Call, Inc., 4425 S. 24th Street, Omaha, Nebraska IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Alzheimers disease or condition resulting Itl;death) s egeentially list COndltiens, if b) any, Igading to the cause listed on line a. -- DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) .(disease or Injury that initiated r the events r,si lting in death) LAST 22a. DATE OF INJURY (Mo., Day, Yr.) STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 9b. COUNTY Hall Not Embalmed 16a. EMBALMER - SIGNATURE 16d. CEMETERY, CREMATORY OR OTHER LOCATION Med Cure DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: d) 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death Q Not pregnant, but pregnant within 42 days of death Not pregnant, : but pregnant 42 days to 1 year before death • la Unknown if pregnant within the past year 22d. INJURY AT WORK? I22e. DESCRIBE HOW INJURY OCCURRED ❑ YES ❑ NO 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 201603146 5a. AGE last Birthday (Yrs ) 85 14a. INFORMANT -NAME Bonnie D Pesek 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined CITY/TOWN 5 23a. DATE OF DEATH (Mo., Day, Yr.) o t January 4, 2016 vi 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH E u Z January 19, 2016 07:20 AM 0 23tl. To the best of my knowledge, death occurred at the time, date and place 2 c and due to the cause(s) stated. (Signature and Title) " z Gary Settje, MD s 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES igjNo ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print, Gary Settje, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28� REGISTRAR'S SIGNATURE i Exhibit "A" : UNDER 1YEAR MOS. DAYS 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient © ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island 9e. APT. NO. 2. SEX Male 6b: LICENSE NO. CAUSE OF DEATH (See instructions and examples) Sc. UNDER 1 DAY HOURS 8d. COUNTY OF DEATH Hall CITY/TOWN 9f. ZIP CODE 68803 Maryland Heights S, PART I. Enter the chain of events -- diseases, injuries, or complications -that directly caused the death. 00 NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Prostate: Cancers 2115. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr. 26a. HAS ORGAN? OR TISSUE DONATION BEEN'' CONSIDERED? ❑ YES 0 NO MINS. STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES OTHER ® Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 3. DATE OF DEATH (Mo., Day, Yr.) January 4, 2016 February 3, 1930 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Bonnie 0 IEvans 1 12. MOTHERS -NAME (First, Middle, Maiden Surname) Barbara Paidar 28b. DATE FILED BY REGISTRA January 19, 2016 6. DATE OF BIRTH (Mo., Day, Yr.) ❑ Hospice Facility 9g. INSIDE CITY LIMITS 0 YES ❑ NO 14b. RELATIONSHIP TO DECEDENT, Spouse 16c. DATE (Mo., Day, Yr.) January 6, 2016 STATE Missouri 17b. Zip' Code 68107 APPROXIMATEs)NTERV onset to death Years onset to d eath onset to death onset to death:' 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO I 22b. TIME OF INJURY ) 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 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) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES :: ® 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE Of DEATH? ❑ YES ❑ NO (M ., Day, Yr.)