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STATE OF NEBRASKA 6 , tr;i4 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 4/26/2017 LINCOLN, NEBRASKA 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, 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 CAL'SE (Final a) Resoiratory Failure disease or condition resulting APPROXIMATEINTERVAL:: onset to death Hours � 1. DECEDENTS-NAME (First, Middle, Last, Suffix) Lavern Robert Kowalski 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Greeley, Nebraska 7. SOCIAL SECURITY NUMBER 507 -54 -2615 b. FACILITY - NAME (ff not Institution, give street and number) CHI Health Good Samaritan C4 f7 i ct i. 8c. CITY OR TOWN OF DEATH (Include Zip Code) Kearney 68848 9a. RESIDENCE -STATE z Nebraska 9d. STREET AND NUMBER 2320 N Park Avenue 73 10a. MARITAL STATUS AT TIME OF DEATH 2 Married ❑ Never Married ie ❑ Married but separated:; ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) V, Roman Kowalski 9b. COUNTY Hall 1 12. MOTHER'S-NAME (First, Margaret Czarnik Middle, Maiden Surname) E - 13. EVER IN U.S, ARMED FORCES? Give dates of service if Yes. c (Yes, No or Unit.) NO 2 u is. METHOD OF DISPOSITION i s ❑ Burial ❑ Donation ® Cremation ❑ Entombment 0 Removal ;:❑ Otfter,: (Specify) 16a. EMBALMER- SIGNATURE Not Embalmed 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY/TOWN Gibbon STATE Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Ord Memorial Chapel. Inc., 1005 North 28th Street, PO Box 230. Ord. Nebraska CAUSE OF DEATH (See instructions and examples) in death) Sequentially fist conditions, if any, leading to the cause listed on line 'a DUE TO, OR AS A CONSEQUENCE OF: b) Sepsis onset to deaths; Days DUE TO, OR AS A CONSEQUENCE OF: c)Astrocytoma ( Brain Tumor) onset to death Enter the UNDERLYING CAUSE tdiseaae or injury Shat ini tiated the events rowiting at dea th) LAST '; DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not resulting in the underlying cause given in PART I. Patient Refused All Treatments And Was On Comfort Cares 2D. IF. FEMALE: ❑ Not pregnant whhin past year 0 Pregnant at time of death 0 Net pregnant, but pregn within 42 days of death Not pregna but pre gnant 43 days to 1 year before death ❑ Unknewn if pregnant within the past year D E 22a. DATE OF INJURY (Mo., Day, Yr.) C .$ 22d. INJURY ATWORK7 ]YES {NO 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 22b. TIME OF INJURY 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident 0 Pending Investigation ❑ Suicide ❑ Could not be determined 22e. DESCRIBE HOW INJURY OCCURRED CITY /TOWN STATE ZIP CODE 28a. REGISTRAR'S 23a. DATE OF DEATH (Mo., Day, Yr.) March 29, 2017 2310. DATE SIGNED (Mo., Day, Yr.) March 30, 2017 SIGNATURE 23c. TIME OF DEATH 10:53 AM 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) Muhammad A Khalid, MD ...... :....... ..... ....... ....... ....................... 5a. AGE - Last Birthday (Yrs.) 7 23. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 10 NO ❑ PROBABLY ❑ UNKNOWN ❑ YES Q NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Muhammad A Khalid, MD, 10 E 31st Street, Kearney, Nebraska, 68847 5b. UNDER 1 YEAR MOS. 8a. PLACE OF DEATH HOSPITAL ® Inpatient 0 ER/Outpatient DOA 0 DAYS 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY HOURS 14a. INFORMANT -NAME Norma Kowalski 16b.. LICENSE NO. 21b, IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) 2 y, 24a. DATE SIGNED (Mo., Day, Yr.) � �<az E z z g ° z : MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 9f. ZIP CODE 68803 3. DATE OF DEATH (Mo., Day, Yr.) March 29, 2017 6. DATE OF BIRTH (Mo., Day, Yr.) July 3, 1943 ❑ Hospice Facility 8d. COUNTY OF DEATH Buffalo 9c. CITY OR TOWN Grand Island 9g. INSIDE CITY LIMITS "" ® YES ❑ NO 10b. NAME OF SPOUSE (First, Norma _ Jensen Middle, Last, Suffix) If wife, give maiden name 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) March 30, 2017 17b. Zip Code 68862 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO • 21c. WAS AN AUTOPSY PERFORM ❑YES 50 NO 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) 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and/or investigation, in my opinion deathpccurred at the time, date and place and due to the cause(s) stated. (Signature. and Tide) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 0 NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) March 31, 2017 20170412g STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH