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To be completedNerified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Francis LeRoy Sowl 2. SEX •. Male 3. DATE OF DEATH (Mo., Day, Yr.) November 1, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Fullerton, Nebraska 5a. AGE - Last Birthday (Yrs.) 73 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) March 3, 1939 MOS. I DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -48 -2105 8b. FACILITY -NAME (If not Institution, give street and number) 1434 Piper 8a. PLAtF DEATH HOSP(jAL ❑ Inpatient OTHE$ ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ERloutpatient • El Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) ! ' " Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIRESIDENCE-STATE Nebraska 8b. COUNTY I Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1434 Piper 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Darlene Sue Stack 11. FATHER'S -NAME (First, Middle, Last, Suffix) Edward Marshall Sowl 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mabel Ruth Nelson 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 04/30/1957- 03/26/1960 14a. INFORMANT -NAME Darlene Sue Sowl 14b. RELATIONSHIP TO DECEDENT Wife 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.) November 2, 2012 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Crematory Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING 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) To be completed by: CERTIFIER 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 Immediate 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) Respiratory Failure disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Myocardial Infarction Immediate any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Chronic Obstructive Pulmonary Disease Years (disease or injury that initiated _ the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) Untreated Diabetes Years 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART I. Fibromyalgia 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 20. IF FEMALE: ❑ N01 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 ❑Could not be detennined 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 1' W $ E IL J Z 23a. DATE OF DEATH (Mo., Day, Yr.) >;' g z i g E a <. 5 0 N i 8 II '' 24a. DATE SIGNED (Mo., Day, Yr.) November 3, 2012 24b. TIME OF DEATH Approx. 05:00 AM 231'. rUATE SIGNED (Mo., Lilly, Yr.) - i 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) November 1, 2012 24d. TIME PRONOUNCED DEAD 08:25 AM 8 u 0 3d. To the best of my knowledge, death occurred at the time, date and place c c and due to the causes) stated. (Signature and Title) � ' 24e. On INC 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 Tale) Jon Hendricks, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN 26a. HAS ORGAN OR TISSUONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jon Hendricks, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 28a. REGISTRAR'S SIGNATURE ��, / j ei I 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I November 5, 2012 DATE OF ISSUANCE 01/23/2013 LINCOLN, NEBRASKA STATE OF NEBRASKA 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 ilITALREdORDS. , 201700078 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S COOPER ASSISTA 7 T R DEPART OF HUMAN S RVIdS