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To be completed /verified by: FUNERAL DIRECTOR I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Leonard Lee Boltz 2. SEX f - MAle 3. DATE OR DEATH (Mo., Day, Yr.) May 3, 2015 ,. 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 77 5b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) March 8, 1938 MOS. DAYS HOURS- - MINS. 7. SOCIAL SECURITY NUMBER 506 -50 -8326 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8a. PLACE OF DEATH HOSPITAL IN Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other(Specify) 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 3838 North 70th Road 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 Lorraine K Madsen 11. FATHER'S -NAME (First, Middle, Last, Suffix) Fred Boltz 12. MOTHERS-NAME (First, Middle, Maiden Surname) Edna Rauert 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 05/26/1957- 04/25/1959 14a. INFORMANT -NAME Lorraine K Boltz 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Tracey Dietz 16b. LICENSE NO. 1328 16c. DATE (Mo., Day, Yr.) May 9, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 To be completed by: CERTIFIER 1 1 CAUSE OF DEATH (See instructions and examples) 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 Days 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) Post Obstructive Pneumonia disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death Sequentially list conditions, if b) Squamous Cell Carcinoma Of Lung With Metastasis To Spine Related To 1 Months any, leading to the cause listed Asbestosis - service Related 1 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: ; onset to death Enter the UNDERLYING CAUSE c) Tobacco Abuse 1 Years (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) 1 1 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Asbestosis, Chronic obstructive lung disease, Dysphagia 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO ). IF FEMALE: ❑ Not pregnant within past year 9 0 Pre nant at time of deatA ❑ 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 ❑ Accitlent ❑ Pe gation ❑ Suicide ❑ Could not be detemiined 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 To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) May 3, 2015 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) May 8, 2015 23c. TIME OF DEATH 05:35 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Jay C. Anderson, MD 24e, On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cau e(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR ISSUE DONATION BEEN CONSIDERED? ❑ YES 0 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 8803 28a. REGISTRAR'S SIGNATURE I 28 b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) May 8, 2015 DATE OF ISSUANCE 05/11/2015 STATE OF NEBRASKA 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 NEBRASKkbARI OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR '16ITt9f.i QRrD t n^ «K ST /NLEY S...CQPPER . ` .A$SIS STATE REGISTRAR DEPA T,,{ l EAL7 -I AND LINCOLN, NEBRASKA ,HUMAP STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SEJtb7C CERTIFICATE OF DEATH I'r