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15 STATE OF NEBRASKA �a^ i =Fi' weisaWe F t3 5 J 2 i2 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Lawrence Emil Dubas 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Palmer, Nebraska 7. SOCIAL SECURITY NUMBER 505 -54- 4337 8b. FAGILITY•NAME (If not Institution, give street and number) CHI Health St. Fran 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE-STATE Nebraska Sd. STREET AND NUMBER 504 N Sherman Avenue 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated 0 Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME Frank Dubas 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or unk.) Yes . Dates Unknown 15. METHOD OF DISPOSITION ® Buriat ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal 0 Other (Specify) tia. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, Stat All Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska 19. PART1, Enter the n of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter tennina respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause On a IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final disease or condition resulting in death) Sequentially lief conditions, it any, ieadingto the cause listed on line a. Enter the UNDERLYING CAUSE ( disease or injury that Initiatad file events resuaing:in death) tASt 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Hereditary Helnorrhag(C Telangiectasia, Aortic Stenosis, Hypertension 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ pre, b pregnant within 42 days of death Ndt Not pregnant but pregnant 43 days to 1 year before death ❑ Unknown if ptegnam within Inc past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK ? 's ❑YES ❑ NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. " YT 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 3/17/2017 LINCOLN NESRASKA Middle, Last, Suffix) 23a. DATE OF DEATH (Mo., Day, Yr.) March 6, 2017 9b. COUNTY Hall 16a. EMBALMER-SIGNATURE Katie M. Smvdra 16d. CEMETERY, CREMATORY OR OTHER LOCATION Fullerton Cemetery a) Metastatic Small Cell Lung Cancer DUE TO, OR AS A CONSEQUENCE OF: b)Severe Chronic Obstructive Pulmonary 'I DUE TO, OR AS A CONSEQUENCE OF: c) Smoking DUE TO, OR AS A CONSEQUENCE OF: i' 22b. TIME OF INJURY CAUSE OF DE T 22e. DESCRIBE HOW INJURY OCCURRED 23b. DATE SIGNEU' Day, Yr.) 23c. TIME OF DEATH March 8, 2017 06:22 AM Sd. To the best of my knowledge, death occurred at the time, date and place and due to the causes) stated. (Signature and Title) William Landis, MD 20170216 ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 5a, AGE - Last Birthday (Yrs.) CITY/TOWN 71 8a. PLACE OF DEATH HOSPITAL E Inpatient ❑ ER/Outpatient 0 DOA 9c. CITY OR TOWN Grand Island lOb. NAME OF SPOUSE (First, Middle, Bonnie Marie Ziemba I 12. MOTHERS -NAME (First, Middle, Frances Szewczyk 14a. INFORMANT- NAME Bonnie Marie Dubas e ns exam In ructi b, UNDER 1 YEAR MOS. DAYS 1454 d 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Gould net be determined 5. DID TOBACOG USE G.ONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES 10 NO 1 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print William Landis, MD, 2444 W. Faidley Avenue, Grand Island Nebraska, 68803 I lse. REGISTRAR'S SIGNATURE 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 6b. LICENSE NO. CITY / TOWN Fullerton les events such as cardiac arrest, line. Add additional lines if necessary. 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger 0 Pedestrian 0 Other (Specify) STATE 4a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr. CONSIDERED? A coop 3. DATE OF DEATH (Mo., Day, Yr.) March 6,2017 6. DATE OF BIRTH (Mo., Day, Yr.) August 28 1945 9f. ZIP CODE 68803 Last, Suffix) If wife, give maiden name Maiden Surname) ❑ YES ® NO 24b. TIME OF DEATH 17 033 ❑ Hospice Facility 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse lac. DATE (Mo., Day, Yr.) March 9, 2017 STATE Nebraska 17b. Zip Code 68801 APPROXIMATE IN TERVAL onset to death 8 Months onset to ` i 5 Years onset to death 40 Years onset totfaath 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED? 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) 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 cause(s) stated. (Signature and Title) 26b. WAS CONSENT GRANTED Not Applicable If 26a is NO ❑ YES 0 N 28b. DATE FILED BY REGISTRAR (Ma, Day, Yr.) March 13, 2017