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STATE OF NEBRASKA marls. °da'AS= e9n � 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 IfEALTH AND HUMAN RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS 241741094 DATE OF ISSUANCE 9/13/2016 LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH SERVICES, VITAL A Cotri STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES w r 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Robert W Spanel 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Rural Anselhio, Nebraska 7. SOCIAL. SECURITY NUMBER 507 -32 -7111 Ski. FACILITY -NAME (If not institution, give street and number) CHI Health Bergen Mercy . RESIDENCE -STATE Nebraska 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 0 Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. °v (Yes, No, or Urlk.) Yes 04/29/1949-03/28/1953 , j METHOD OP DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) L- 0.IFEEMALE • ❑ Not pregnant within past year fW? ❑Pregnant at time of death • ❑ Not Pregnant, but pregnant within 42 days of death '¢ ❑ Net m ` pregnant, abut Pregnant 43 days to 1 year before death ❑ 1,Ihknown if pregnant Within the past year E 22a. DATE OF INJURY (Mo., Day, Yr.) 0 V a 22d. INJURY ATWORK? .: .0 ❑ YES ❑ NO 16a. EMBALMER - SIGNATURE Judson J. Dannehl 22b. TIME OF INJURY 23a. DATE OF DEATH (Mo., Day, Yr.) Autfust 29, 2016 3 rc 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH i; z September 8, 2016 01:35 AM 4 0 > 3d. To the best of my knowledge, death occurred at the time, date and place Z O and due to the cause(s) stated. (Signature and Title) '� Mohana I..DYa; MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? a YES LO NO ❑ PROBABLY ❑ UNKNOWN 28a.:R EGISTRAR.'S SIGNATURE 5a. AGE - Last Birthday (Yrs.) 87 9b. COUNTY Douglas 14a. INFORMANT -NAME Phyllis Spanel 5b. UNDER 1 YEAR MOS. 9d. STREET AND NUMBER 900 N. 90th St DAYS 8c. CITY OR TOWN OF DEATH (Include Zip Code) Omaha 6$124 16b. LICENSE NO. 1273 2. SEX Male 5c. UNDER 1 DAY HOURS 9e. APT. NO. 219 MINS. 9f. ZIP CODE 68114 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21a. MANNER OF DEATH ® Natural 0 Homicide ❑ Accident ❑ Pending Investigation 0 Suicide ❑ Could not be determined 21b. IF TRANSPORTATION 0 Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) INJURY 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE • • ATION BEEN CONSIDERED? ❑ YES 2 NO 3. DATE OF DEATH (Mo., Day, Yr.) August 29, 2016 July 3, 1929 6. DATE OF BIRTH (Mo., Day, 'tr.) 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home/LTC ❑ Decedent's Home ❑ Other (Specify) Hospice Facility 8d. COUNTY OF DEATH Douglas 9c. CITY OR TOWN Omaha 9g. INSIDE CITY LIMITS ® YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Phyllis Lewandowski 11. FATHER'S•NAME (First, Middle, Last, Suffix) Frank Jr Spanel 1 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Caroline Knoell 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr) September 3, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Grand Island City Cemetery Grand Island STATE Nebraska' 17a. FUNERAL NAME NAME AND MAILING ADDRESS (Street, City or Town, State) Curran Funeral Chapel. 3005 S. Locust St.. Grand Island. Nebraska 17b. Zip Code 68801 CAUSE OF DEATH ,See instructions and examples) 1S. PART 1. Enter the'shain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest or ventriOular 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) Cardiorespiratory Arrest dise nr cnnr tion esuiting APPROXIMATE: INTERVAL onset to death Uilkriown in death) Sequentially list toiiditioris if any kiadine to the cause Listed DUE TO, OR AS A CONSEQUENCE OF: b)Metastatic Cancer, Adenocarcinoma. Primary Site Unknown. History Of Prostate and Lung Cancer onset to death Enter the UNDERLYING CAUSE (disease or injury that initiated DUE TO, OR AS A CONSEQUENCE OF: C) onset to death the events resphingan LAST .. DUE TO, OR AS A CONSEQUENCE OF: d) onset to Death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ET NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ?: ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED. 22f. LOCATION' OF INJURY STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE TIME OF DEATH 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and /or investiga ion, in my opinion death occurred at the time, date and place and due to the causes) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a ($ NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Mohana Loyal M.O, 7500 Mercy Rd, Omaha, Nebraska, 68124 28b. DATE FILED BY REGISTRAR (MO., Day, Yr.) September 7, 2016