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To be completed by: CERTIFIER 1 1 To be completed/verified by: FUNERAL DIRECTOR J 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Maynard Dwight Desel 2. SEX Male' 3. DATE OF.DEATH (Mo., Day, Yr.) January 24, 2016 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Loup City, Nebraska 5a. AGE - Last Birthday (Yrs.) 92 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) August 9, 1923 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -32 -8231 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other(Specify) Bb. FACILITY -NAME (If not Institution, give street and number) Grand Island Veterans Home 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 Wood River 9d. STREET AND NUMBER 505 East 11th Street 9e. APT. NO. 9f. ZIP CODE 68883 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 Mary Fish 11. FATHER'S -NAME (First, Middle, Last, Suffix) Carl Desel 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ina Noyes 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 03/22/1945 - 11/28/1946 14a. INFORMANT -NAME Susan Guzinski 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Chris McCoy 16b. LICENSE NO. 1191 16c. DATE (Mo., Day, Yr.) January 28, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services • Gibbon Nebraska 17a. FUNERAL HOME NAME AND.MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, 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 Tines if necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final a) Fluid Overload 1 Week disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, H b) Congestive Heart Failure > 10 Years any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) I (disease or injury that Initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death LAST d) I 1 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART 1. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES Ea 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 0 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 El 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 a W i rc r E EI 23a. DATE OF DEATH (Mo., Day, Yr.) January 24, 2016 Z r e s z Y 2 ,. o 0. ± < u w z o C u ~ 0 s 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) January 25,2016 23c. TIME OF DEATH 12:25 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD g � 0 7d. To the best of my knowledge, death occurred at the time, date and place 2 o C and due to the cause(s) stated (Signature and Title) '- * Douglas J. Morin, 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 rue) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR ❑ YES ISSUE DONATION BEEN CONSIDERED? 13 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Douglas J. Morin, MD, 2300 West Capital Avenue, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE A .. 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) January 29, 2016 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 DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITALRECORDS. DATE OF ISSUANCE 02/05/2016 LINCOLN, NEBRASKA STATE OF NEBRASKA 201604054 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE$ CERTIFICATE OF DEATH STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH-AND HUMAN SERVICES 16,00448