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DATE OF ISSUANCE 04/14/2016 LINCOLN NEBRASKA STATE OF NEBRASKA 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 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENTS -NAME (First, Middle, - Last, Suffix) Richard Lee Hodtwalker 4.::.CITY.AND: STATE OR .TERRITORY, OR FOREIGN COUNTRY OF BIRTH G Island:; Nebr 7. SOCIAL SECURITY NUMBER 505 -48- 5754 8b: FACILITY -NAME (If not Institution, give street and number) Wedgeyvood Care::Ce me r O:. r.: U' W ce 0 vt. Nebraska 9d. STREET AND NUMBER a 2931 Idaho Avenue I E . 9a. RE$IDENCE•STATE :: 9b. COUNTY Hall 1 Oa. MARITAL STATUS , TIME OF DEATH El Married ❑ Never Married Married, ttut separated ❑ Widowed ❑ Divorced ❑ Unknown 13. EVER:I:N U.S Give dates of service if Yes. (Yes, Ng .or Un Yes :02/16/1966 - 01/12/1970 0. METHOD or DISPOSITION ❑ Burial ❑ Donation El Cremation ❑ Entombment Removal 0 Other. (Specify) 17a.'FUNERAL:Hom NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 72 5b. UNDER 1 YEAR MOS. 9c. CITY OR TOWN Grand Island 16a. EMBALMER- SIGNATURE Not Embalmed DAYS 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER fJ Nursing Horne/LTC ❑ Hospice Facility ❑. ER/Outpatient ❑ Decedent's Home DOA . ❑ Other (Specify) 14a. INFORMANT -NAME Elizabeth Ann Hodtwalker 8d. COUNTY OF DEATH Hall 9e. APT. NO. 9f. ZIP CODE 68803 1013. NAME OF SPOUSE (First, : Middle, Last, Suffix) If wife, give maiden name Elizabeth Ann Vipperman it FATHER'S -NAME (Rrst, Middle, Last, Suffix) Kenneth Hodtwalker 1 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ruth Tyler 16b. LICENSE NO. 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation: Services:. Gibbon STATE ....Nebraska CAUSE OF DEATH (See instructions and examples) Is. PART I. Enter the5hain of events - -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal such as cardiac arrest, respiratory: arrest, or.venttioular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one eause::on a lipe. Add additional lines If necessary. IMMEDIATE CAUSE: a) Lung Cancer IMMEDIATE CAUSE (Final disease or condition resulting APPROXIMATE :INTERVAL onset to death 6 Months .in. deaths . Sequentially: list conditions, Ifs: any leeding'to the cause listed on line a DUE TO, OR AS A CONSEQUENCE OF: b)Tobacco Abuse onset to death::. Years::: DUE TO, OR AS A CONSEQUENCE OF: C) onset to death Enter the UNDERLYING CAUSE (disease >.or.injury that initiated::: .Events resultin in death) LAST d) DUE TO, OR AS A CONSEQUENCE OF: , onset to deate: 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 20. IF FEMALE:: ❑ Nat pregnant within pest year ❑ Pregnant at time of death Not Pregnant; but pregnant within 42 days of death Not pregnant,:but pregnant43 days to 1 year before death ❑:: linkrtown ik:pr the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. )NJ U RY. Ar.yIIOR3( ?.:; ygs 22b. TIME OF INJURY 21a. MANNER OF DEATH ® Natural ❑ Hbmlcide .. ❑ Accident ❑ Pending Investigation ❑ Suicide ❑Could not be determined 21b..IF TRANSPORTATION ❑: Driver /Operator ❑ Passenger 0 .pedestrian ❑ Other. (Specify) INJURY 3. DATE OF DEATH (Mo., Day, Yr.) April 9, 2016 6. DATE OF BIRTH (Mo., Day, : Yr) March 8, 1944 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) April 11, 2016 17b. Zip Code 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES : ❑ : NO 21c. WAS AN AUTOPSY PERFORMED? ❑YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? ❑ YES ❑ NO., . 22c. PLACE OF INJURY - home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) April 9„ 2016 23b. DATE SIGNED (Ma., Day, Yr.) April 11, 2016 Douglas `Herbek, MD 23c. TIME OF DEATH 10:00 PM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the causes) stated. (Signature and Title) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YEs [ NO 1 PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 28a. REGISTRAR'S SIGNATURE 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 0 YES ❑: NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Douglas Herb 2444 W. Faidley Avenue Grand Island, Nebraska, 68803 28b. DATE FILED BY REGISTRAR.(Mc.:.Day, Yr.) .:::. April 12, 2016