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To be completed by: CERTIFIER I I To be completed /verified by: FUNERAL DIRECTOR I 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Kenneth Dale Link IBEX, ,` ', , Mare'. 2. EtO TH.(Mo., Day, Yr.) ` `March t7,'2a15° 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Broken Bow, Nebraska 5a. AGE - Last Birthday (Yrs.) 78 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) February 18, 1937 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507-42 -3319 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Home ❑ DOA ❑ Other (Specify) 8b. FACILITY -NAME (If not Institution, give street and number) 2215 W. 1 -4t:: Strzet 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 Grand Island 9d. STREET AND NUMBER 2215 W. 14th Street 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ 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 Virginia Lou Smith 11. FATHER'S -NAME (First, Middle, Last, Suffix) Horatio Link 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Beulah Fields 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 03/1958- 03/1960 14a. INFORMANT -NAME Virginia Lou Link 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Kevin Wood 16b. LICENSE NO. 1325 16c. DATE (Mo., Day, Yr.) March 21, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston - Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska CAUSE • F DEATH See instructions and exam ales 1 8. 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 respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary. IMMEDIATE CAUSE: onset IMMEDIATE CAUSE (Final a) Congestive Heart Failure End Stage 3 Years 17b. Zip Code 68803 INTERVAL to death n death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b)Chronic Kidney Disease 3 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) Ascites 3 Years (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting In the underlying cause given in PART I. Diabetes, Atrial Fibrillation onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® 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 the 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 ® NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) ❑ Unknown if pregnant within past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? DYES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH IMo.. Day. Yr.I 2e.0 naTr• cir_MFn (Mn , n-•!, V : ,) ;; 6 March 17, 2015 u _4l: nf.P !`F DEATH i F 23b. DATE SIGNED (Mo., Day, Yr.) EEj i March 20,2015 23c. TIME OF DEATH i E 2 Y ' PRONOUNCED DEAD (Mo., Day, Yr. 05:17 PM o o. *8c 24d. TIME PRONOUNCED DEAD a 0 23d. To the best of my knowledge, death occurred at the time, date and place 8 w z 24e. On the ba examination 2 9 and due to the cause(s) stated. (Signature and Title) g C u the time, date sis oT and place and and o e) f Douglas Herbek, MD ~ o o 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO l investigon, in my opinion death occurred at du e to the ca stated. (Signature and Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO . D a.' • - IFIE ypeor - rnt Douglas Herbek, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE `� , " 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) March 23, 2015 Z 1.2 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 DT ARI'MENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.' { . i DATE OF ISSUANCE 03/31/2015 LINCOLN, NEBRASKA STATE OF NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN „SERVICES CERTIFICATE OF DEATH : : �` STANLEY S C O O P E R ASSISTANTSTATE REGISTRAR QEPARTfr1 NT OF HEALTH AND HUMAN SERVICES` 15 01715