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STATE OF NEBRASKA f3� -Iteatirflffi 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Donald John Lanzendorf 4. •CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 7. SOCIAL SECURITY NUMBER 485 -30 -3435 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 i s RESIDENCE - STATE Nebraska 9d. STREET AND NUMBER 2915 West Anna Street 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 3/10/2017 LINCOLN, NEBRASKA Owens, Iowa . FACILITY -NAME (if tint give street and number) 2915 West Anna Street 9b, COUNTY Hall Oa. MARITAL STATUS AT TIME OF DEATH 1 Married ❑ Never Married ❑ Married, but separated'; ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) George Lanzendorf 13. EVER IN U.S, ARMED ORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 07/22/ 949 - 10/09/1952 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation Cremation ❑ Entombment ❑ Rernovai ;❑ Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) ADfel Funeral Home. 1123 W. 2nd. Grand island. Nebraska IMMEDIATE CAUSE (Final disease or condition resulting death] Sequentially list conditions, if any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE {disease dr Injury Mat initiated the events resulting t o death) ; DUE TO, OR AS A CONSEQUENCE OF: LASI .. d) 20.IFFEMALEt . ❑ Not pregnant whhin past year ❑. Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑Not pregnant, but pregnant days to 1 year before death ❑ Unknown Itpregnantwithi &the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 2d.;INJURY ATWORK? ❑ 'Es ❑NO 16a. EMBALMER - SIGNATURE DUE TO, OR AS A CONSEQUENCE OF: b) Cardiac Arrest DUE TO, OR AS A CONSEQUENCE OF: C) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 23a. DATE OF DEATH (Mo., Day, Yr.) 23b. DATE SIGNED (Mo, Day, Yr.) 3d. To the best of my knowledge, death occurred :;t the time, date and p!ece and due to the cause(s) stated. (Signature and Title) 23c. TIME OF DEATH 201702199 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 5a. AGE - Last Birthday fib. UNDER 1 YEAR (Yrs.) CITY/TOWN 85 14a. INFORMANT -NAME Pansy Lanzendorf MOS. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island DAYS STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 9e. APT. NO. 16b, LICENSE NO. Not Embalmed 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services Gibbon 2. SEX Male 5c. UNDER 1 DAY HOURS 8d. COUNTY OF DEATH Hall CITY / TOWN 9f. ZIP CODE 68801 car MINS. OTHER ❑ Nursing Home/LTC ® Decedent's Home ❑ Other (Specify) 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Pansy Parker 1 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Elizabeth Gangler CAUSE OF DEATH _See instruct)ons and examples) 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 ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined ❑ Driver /Operator ❑ YES ❑ Passenger ® NO 0 Pedestrian ❑ Other(Specify) 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) s a STATE 24a. DATE SIGNED (Mo., Day, Yr.) February 27, 2017 24c. PRONOUNCED DEAD (Mo., Day, Yr.) February 25, 2017 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 Tide) Matthew C. Boyle, Hall Deputy County Attorney 3. DATE OF DEATH (Mo., Day, Yr.) February 25, 2017 24b. TIME OF DEATH Approx. 06;00 AM 6. DATE OF BIRTH. (MG Day, Yr.) December 22 1931 1 9g. INSIDE CITY LIMITS ' ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) February 27, 2017 STATE Nebraska PI. PART 1. Enter the ehain advents- - diseases, injuries, or complications-that directly caused the death, DO NOT enter events such as cardiac arrest, APPROXIMATES INTERVAL tespiratory arrest, or ventridular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause: on a line. Add additional lines if necessary. IMMEDIATE CAUSE: a) Respiratory Failure onset to death Immediate onset to dead) Immediate onset to death onset to dea(h 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF D EATH '2: ❑ YES ❑ NO 24d. TIME PRONOUNCED DEAD 09:50 AM _ 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN:OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? ❑ YES E NO ❑ PROBABLY ❑ UNKNOWN ❑ YES J NO Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Matthew C. Boyle, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 Ar A _ " 28b. DATE FILED BY REGISTRAI 8a. REGISTRAR'S SIGNATURE March 6, 2017 `ZIP CODE ,