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Ib ,eattE K al W / X w ". .,d 4 Mara.Lwb i AAi[All 1 h,SA Ale...PIN' 'us STATE OF NEBRASKA , q b #9 s I ,ta4� 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 CCOOMA RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS A- 201702134 DEPARTMENT HEALTH AND G1STRAR HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH! AND HUMAN SERVICES CERTIFICATE OF DEATH DATE OF ISSUANCE 3/14/2017 LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Lawrence Frank Bosak ITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Fullerton, Nebraska 7. SOCIAL SECURITY NUMBER 507 -74 -5044 _.� 8b. FACILrTY - NAME (If not Institution, give street and number) 0 t�"i 3012 Orleans Dr(ve x 8c. CITY OR TOWN OF DEATH (Include Zip Code) . Grand Island. 6$803 9a. RESIDENCE.STATE w Nebraska LL 9d. STREET AND NUMBER 3012 Orleans Drive 10a. MARITAL STATUS AT TIME OF DEATH El Married 0 Never Married E ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Edward John Bosak 0 E 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. U (Yes' No or unk.) Yes °03/14/1977- 06/30/1994 $' 1 5. METHOD OF DISPOSITION ,22 ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Small Bowel Obstruction disease or condition resulting in: death) z: eque daily list cdndltiotttt if any, leading to the Cause listed on line a. Enter the UNDERLYING CAUSE tdisease or injury that ini8ated the events resulting in death) tAST'> 20. IF EMALE: 1 ❑ Not pregnant Within past year UJ ❑ pregnant at time of death U ❑ yot pregnant,put pregnant within 42 days of death ❑ Net pregnant.twt pregnant 43 days to 1 year before death D. Unknown if pr past year c 22a. DATE OF INJURY (Mo., Day, Yr.) 0 22d. INJURY AT:WORK? ❑YlnS CJ NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. a. DATE OP DEATH (Mo., Day, Yr.) M 2 , 2017 23b. DATE SIGNED (Mo., Day, Yr.) March 3, 2017 25. Dt0 TOBACCO USECQNTRIBUTE TO THE DEATH? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 5a. AGE - Last Birthday (Yrs.) 63 9b. COUNTY Hall lob. NAME OF SPOUSE (First, 16a. EMBALMER-SIGNATURE Matthew T. Myers 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 22e. DESCRIBE HOW INJURY OCCURRED 23c. TIME OF DEATH 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 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Larry L. Hansen, MD, 3016 West Faidley, Grand Island, Nebraska, a _ 28a. REGISTRARS SIGNATURE j6 - ti 5b. UNDER 1 YEAR MOS. DAYS 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livinoston-Sondermann Funeral Home, 601 N. Webb Road. Grand island. Nebraska 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 9c. CITY OR TOWN Grand !Island' 2. SEX Male 5c. UNDER 1 DAY HOURS 8d. COUNTY OF DEATH Hall 9e. APT. NO. 9f. ZIP CODE 68803 Middle, Last, Suffix) If wife, gi Barbara Bosak I : 12. MOTHER'S -NAME (First, Middle, Mary Catherine Downing MINS. 3. 6 Maiden 14a. INFORMANT -NAME Barbara Bosak 16b. LICENSE NO. 1411 CITY /TOWN Grand Island CAUSE OF DEATH (See instructions and examples) t. PART t. Enter the chain of events-diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause Ott a line. Add additional lines if necessary. 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) CITY/TOWN STATE 21d. WE TO 22b. TIME OF INJURY 1 22c. PLACE OF INJURY -At home, farm, street, factory, office building, cons 24a. DATE SIGNED (Mo., Day, Yr.) 24b. 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. 24e. On the basis of examination and /or investigation, i the time, date and place and due to the cause(s) s 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? DYES 411 NO 26b. WAS CON Not Applicable if 28b. DATE FILED March 9, 20 DATE OF DEATH (Mo., Day, Yr.) March 2, 2017 DATE OF BIRTH (Mo,, Day February 26, ve maiden name 954 OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ® Decedent's Home ❑ Other (Specify) 9g. INSIDE CITY LIMITS !' ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse . 16c. DATE: (Mo., Day,Yr.) March 2, 2017 STATE Nebraska 17b. Zip Code 68803 r,) AP PROXIMATE :INTERV onset to death 1 Week onset to death: 1 Year onset to death 7 Years onset to death 40 Years 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO YES ❑ NO ruction site, etc. (Specify) TIME OF DEATH TIME PRONOUNCED DEAD my opinion death occurred at ted. (Signature and Tide) SENT GRANTED? 26a is NO ❑.YES RE AUTOPSY FINDINGS AVAILABLE COMPLETE CAUSE OF DEATH/ >