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STATE OF NEBRASKA 0 CC w z u . LL a tb w 0. 1- - re W u ti E 0 it7 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 DATE OF ISSUANCE 3/14/2017 LINCOLN, NEBRASKA DECEDENTS - NAME (First, Middle, Last, Suffix) Lawrence Frank Bosak 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Fullerton, Nebraska 7. SOCIAL SECURITY NUMBER 507 -74 -5044 8b. FACILITY -NAME (If not Institution, give street and number) 3012 Orleans Drive CITY OR TOWN OF DEATH (Include Zip Code) Grand Island. 68803 9a. RESIDENCE -SLAT Nebraska 9d. STREET AND NUMBER 3012 Orleans Drive 1f)4 . MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated i,❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Edward John Bosak 13. IN U,S, ARMED: FORCES? Give dates of service if Yes. (Yes,, No, or Dos.) Yes .03/14/1977- 06/30/1994 16. METHOD OF DISPOSITION' ❑ Burial ❑ Donation Matthew T. Myers ® Cremation ❑ Entombment Removal .0 Other (Specify) IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Small Bowel Obstruction disease or condition resulting ath) cequenhaay fist conditions, it ny, leading to the cause listed; on line a,.._. Enter the UNDERLYING CAUSE (disease or injury that initiated the events reeuking'n death) LAST 20. IF FEMALE: ❑ Not pregnant within past year ❑. Pregnant at time of death 0 Not pregnant, but pregnant within 42 days of death ❑ NO pregnant, hut pregnant 43 days to 1 year before death ❑ Unknown I pregnant Mafia the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INI URY AT Y. IIORK? ❑YES O',No STATE OF NEBRASKA - DEPARTMENT OF H 9b. COUNTY Hall 16a. EMBALMER-SIGNATURE 201702133 CERTIFICATE 0 5a. AGE - Last Birthday (Yrs.) 63 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Memorial Park Crematory DUE TO, OR AS A CONSEQUENCE OF: b)Metastatic Cancer DUE TO, OR AS A CONSEQUENCE OF: c) Non' Small Cell Lung Cancer DUE TO, OR AS A CONSEQUENCE OF: d)Tobacco Abuse 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITY /TOWN 231 DATE OP DEATH (Mo., Day, Yr.) Match 2 20:')7 23b DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH March 3, 2017 01:37 PM 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) Larry L. Hansen, MD 5b; UNDER 1 YEAR MOS, . 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA . CITY OR TOWN Grand Island I 12. MOTHER'S -NAME (First, Mary Catherine Downing 14a. INFORMANT - NAME Barbara Bosak 7a. FUNERAL HOME NAMES AND MA LING ADDRESS (Street, City or Town, State) Livingston - Sondermann Funeral Home. 601 N. Webb Road. Grand Island, Nebraska 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined DAYS 9e. APT. NO. EALTH AND HUMAN SERVICES F DEATH 2. SEX Male 5c. UNDER 1 DAY HOURS 8d. COUNTY OF DEATH Hall 16b. LICENSE NO. 1411 CITY / TOWN Grand Island 24a, DATE SIGNED (Mo., Day, Yr.) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ® YES D NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ®'NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Larry L. Hansen, MD, 3016 West Faidley, Grand Island, Nebraska, 68803 28a. REGISTRARa SIGNATURE /It f ,6- wti STANLEY S. 'COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES MINS. OTHER ❑ Nursing Home /LTC ® Decedent's Home ❑ Other (Specify) 9f. ZIP CODE 68803 CAUSE OF DEATH (See instructions and examples) PART I. Entet the chain of events- - diseases, injuries, or complications -that directly caused the death. DO NOT entetterminal events such as cardiac arrest, respiratory arrestor ventri0.11af fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on aline, Add additional lines if necessary. 8. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Z1b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ Pedestrian Other (Specify) STATE 24c. PRONOUNCED DEAD (Mo., Day, Yr. atipel 3. DATE OF DEATH (Mo., Day, Yr.) March 2, 2017 6. DATE OF BIRTH (Mo. Middle, Maiden Surname) February 26, 1954 tOb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Barbara Bosak onset to death 7 Years ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24b. TIME OF DEATH; 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) ay, Yr; 9g. INSIDE CITY LiM1TS ® YES ❑ NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 14b. RELATIONSHIP TO DECEDENT , Spouse 16c. DATE (Mo., Day, Yr.). March 2, 2017 STATE :Nebraska 17b.Zip.Code 68803 APPROXIMATEINTERVA £ . onset to death 1 Week onset to death 1 Year onset to death 40 Years 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑YES ..]NI? .. 21c. WAS AN AUTOPSY PERFORMED? ❑ YES IZ NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) March 9, 2017