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To Be CompletedNerified by: FUNERAL DIRECTOR I 1. DECEDENTS•NAME (First, Middle, Last, Suffix) _ - - - _ - Joseph Franklin Lahowetz 2. SEX Male 3. DATE OF DEATH (Mo.,Day,Yr.) January 2, 2016 4. CRY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH St. Paul, Nebraska Ea. AGE -Last Birthday (Yes) 83 Sb. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.) November 15, 1932 MOS. DAYS HOURS I MINS. I 7. SOCIAL SECURITY NUMBER _ .. 505 -38 -6952 S. PLACE OF DEATH sularei.: 0 Inpatient maul ® Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent. Home ❑ DOA ❑Othe P CNY) Sb. FACILITY -NAME (I. not InstfhRlon, give street and number) V A Medical Center -Grand Island 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand. Island 68803 6d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall tic. CITY OR TOWN Grand Island Sc. STREET AND NUMBER 1703 North Taylor Avenue 9e. APT. NO. W. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® Y ❑ 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. Marilyn Joyce Dadey 11. FATHER'S -NAME (First, Middle, Last, Suffix) Edward Lahowetz 12. MOTHER'S -NAME (First, Middle, Malden Surname) Lucille Komsak 13. EVER IN U.S. ARMED FORCES? Give dabs of service If Yes. (Ye., No, or URk) Yes 03/1211953-03/08 /1955 14a. INFORMANT -NAME Marilyn Joyce Lahowetz 14b. RELATIONSHIP TO DECEDENT Spouse 16. METHOD OF DISPOSITION 0 BN1e1 00onetion LI Croetion Odetonitudent ❑ , ❑ • tS IryI IS.. EMBALMER - SIGNATURE Not Embalmed 16b. LICENSE NO. 18c. DATE (Me., Day Yr.) January 2016 led CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL. HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 1T0. Zip Code 68801 To Be Completed by: CERTIFIER I CAUSE OF DEATH (See Instructions and examples) II. PART L Enter the MeitutBtiBM- dtaessas, lnjwla, on csmplitWem - that Meetly caused The Meth. DO NOT SAW WNW manta such as ten +neet. APPROXIMATE INTERVAL respiratory me* et vnbidoiar fibrillation without chewing de edelogy. DO NOT ABBREVIATE Enter eery one aua on • Una. Add •ddldwnf ant • Mteary. IMMEDIATE CAUSE: - - - onset to death IMMEDIATE CAUSE (Final C. �- � \�\ e.0.-\ dl a . or condition reautdng a) N .Add Q n C✓ Q�' , tx.� �L/ h DUE TO, OR AS A CONSEQUENCE OF: comet to death anqusntdty to t conditions, the u Ha I l r ` '\ any, leading to the cave listed ,1 b) �A on Om a• DUE TO, OR AS A COHSE NCE OF: onset to death Enter the UNDERLYING CAUSE el ,[(�� ,cam' , L \ UENCE (disease or Injury that initiated DUE RrACONSE O : ` `- the events resulting In death) onset to death LAST a) 18. PART E. OTHER SIGNIFICANT CONDRIONSCondtons contributing ♦ I. I moo` ` " to the death but not resulting In the underlying cause given In PART L . \ \r ■ ■ �. `• ' 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? , A. ❑ NO 20. IF FEMALE: ❑Not pregnant within pat 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 21 MANNER OF DEATH \ Natural ❑ Homicide dent ❑ Pending Investigstton ❑ Set • ❑ Could not be detwmined 21b. IF TRANSPORTATION INJURY ❑ Dever/Operator ❑ Paaenger ❑ Pedestrian ❑ Other (Specify) 21c. W AN AUTOPSY PERFORMED? YES ❑ NO 21d. WER AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 224. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 235. CATE OF DEATH (Mo., Day, Yr.) �• • • G • • • 3 24e. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH m . g 651 nd- sZ 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD m 23d. To the best • s. • knovdedge, death occurred at the time, data and piece and • ue . • • . al stated. (Signature and 110e) B Oi C B o r Iris. On the basis of examination and/or investigation, In my opinion death occurred tints, the s, date and place and due to the cause(s) stated. (Signature and Tide) 26. DI. TOBACCO USE CONTRIBUTE TO THE DEATH? YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 25a. HAS ORGAN OR ' U DONATION SEEN CONSIDERED? ❑ YES it NO 25b. WAS CONSENT GRANTED? Not Applicable H 26. la NO DYES 1LI NO 27. A , TITLE AND ADDRESS OF CERTIFIER (Type or Print) pp�� krK\ceL3 ACeIts PP- �(A�1�:-f-l r.l+rtt .NonoiNah(/Zsla to RRO?) P 28a. REGISTRAR'S SIGNATURE 25b. DATE FILED BY REGISTRAR (Moe, Day, Yr.) ty, I U JAN 11 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' d'EP.41ZTMNT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE 01/14/2016 LINCOLN, NEBRASKA STATE OF NEBRASKA STATE OF. NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES • 201700184 STANLEY S. COOPER ASSISTAIyT,STATE,REGIS7 ;41 DEPARTM F Od HLIALT.H.AND'° K(1MANSERVICE` 1 20042