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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 DAVE OF ISSUANCE 10/13/2016 -40s_r 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Frank Joseph Maixner 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sweetwater, Nebraska 7. SOCIAL SECURITY NUMBER 508 -38 -0020 8 b. FACILITY -NAME (If not Institution, give street and number) f:3 Wedgewood Care Center cc 8c. CITY OR TOWN OF DEATH (Include Zip Code) p Grand Island 68803 5 9a. RESIDENCE -STATE Z Nebraska LL 9d. STREET AND NUMBER 303 South Nubia AGE - Last Birthday (Yrs.) 9b. COUNTY Hall 5b. UNDER 1 YEAR MOS, DAYS 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient © ERIOutpatient ❑ DOA 10a. MARITAL STATUS AT.: TIME OF DEATH ® Married ❑ Never Married 10b. NAME OF SPOUSE (First, n Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown HOURS 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Cairo 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY MINS. OTHER ® Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 9f. ZIP CODE 68824 3. DATE OF DEATH (Mo., Day, Yr.) October 2, 2016 6. DATE OF BIRTH (Mo., Day, Yr.) April 2, 1934 Middle, Last, Suffix) If wife, give maiden name ❑ Hospice Facility 9g. INSIDE CITY LfMITS' 121 YES ❑ NO 23b, DATE S)GNED (Mo., Day, Yr.) October 4 2016 23c. TIME OF DEATH 12:30 PM ieath RVA: LINCOLN NEBRASKA 1. FA THER a OL LTE (F Widuie, Last, Suffix) John Maixner s; EVER TN U.S. FARMED FORCES? Give dates of service if Yes. (Yes, No, or unk.) Yes 04/10/1952-04/30/1972 5. METHOD OF DISPOSITION Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Remoyel ❑ Other (Specify) 7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) ADfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska CAUSE OF DEATH See in ructions and exam r les PART'. Enter the chain of events diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, te`piratery arrest, or vemricujar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one Cause ens line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Emphysema disease or condition resulting in: death) Set}uer tially hat telydrtiona, if b) • any, iehdrng to tie Gaahated se on line a: " -- Enter the UNDERLYING CAUSE {diseaseormjury N)at initiated:: the events resuiting:in death) :. LAST 16a. EMBALMER-SIGNATURE DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 20. IF FEMALE; ❑, Not pregnant v./Rhin past. year ❑ Pregnant at time of death ❑ Not pregnant,:Out pregnant within 42 days of death f ❑ Not pregnant, hot pregnant:43 days to 1 year before death Unknown if pregnant Within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) JURY AT:WORK? .. ❑Yi S .❑NO 22e. DESCRIBE HOW INJURY OCCURRED LOCATION OF INJURY - STREET & NUMBER, APT.NO. WiTE OF DEATH (Mo., Day, October 2 2016 3d. To the best of my knowledge, death occurred at the time, date and place and due to the eause(s) stated. (Signature and Title) Travis S. Haieman, MD 1 28 a. REGlSTRAFPS SIGNATURE Christopher J. Loecker Mt. Pleasant Cemetery 26a. HAS ORGAN OR ❑ YES 2017008/8 STATE OF NEBRASKA - DEPARTMENT OF HEALTH! AND HUMAN SERVICES CERTIFICATE OF DEATH Edna Kerher i 1[. M ✓THERS-i'iA iE ( Rose Sorensen 4a. INFORMANT -NAME Edna Maixner 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN 16b. LICENSE NO. 1421 Cairo 18, PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. MAlnutrition, Weakness 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined I 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) CITY/TOWN 21b. IF TRANSPORTATION INJURY Driver /Operator ❑ Passenger 0 Pedestrian Other (Specify) STATE 4e. DATE p:GUM (Ma, Day, Yr.). 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24e. On the basis of examination and /or investiga ion, in my opinion death occurred the time, date and place and due to the cause(s) stated. (Signature and Title) SSUE DONATION BEEN CONSIDERED? 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES ifiiddie, ataiuen Surname) 14b. RELATIONSHIP TO DECEDENT Spouse ... 16c. DATE (MO Day, Yr.. October 6, 2016 APPROXtMATEIN onset to death Years onset to death onset to death • onset to STATE Nebraska'' 17b. Zip 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES J NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? :. ❑ YES ❑ NO 24d. TIME PRONOUI 24b. TIME OF DEATH 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ED DEAD 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 5 2016 O CD CD INJ CT) CD