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STATE OF NEBRASKA Miler 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 5/23/2017 LINCOI -N, NEBRASKA 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Marianne G Koziol CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Silver Creek, Nebraska 7. SOCIAL SECURITY NUMBER 505 -36 -2844 b. FACILITY-NAME (If not Institution, give street and number) Tiffany Square Care Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 3119 West Faidley Avenue 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but Separated !® Widowed ❑ Divorced ❑ Unknown 11. FATHER'S•NAME (First, Middle, Last, Suffix) Philip Sock 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes,: No, or Unk.) NO 15. METHOD OF DISPOSITION' ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 17a. FUNERAL HOME IIIAMEAND MA LING ADDRESS (Street, City or Town, Sta te) Curran Funeral Chapel, 3005 S. Locust St.. Grand Island. Nebraska 1d, PARTI. Entef the -Chain of respiratory awes` IMMEDIATE CAUSE (Final disease or condition resulting eguetltlally list Conflitions, if any, leading to the cause listed on line a. _. �:... .... DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury that initiated the everts resulting in death) LAST..;" ... .. 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Cardiomyopathy, Atrial Fibrillation 0:1F FEMALE: 0 Not pregnant within past year ❑ Pregnant at time of death . 0 Not pregnant, but pregnant within 42 days of death Notpregnant, but pregnant 43 lays to 1 year before death Unknown ,f pregnant wdhm She past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d9N,IURY AT WORK? OYES'11110NP 22f. LOCATION OF'1NJURY - STREET & NUMBER, APT.NO. Vents - -diseases, injuries, or complications -that directly caused the death. DO- NOT enter terminal events such as cardiac arrest, icglar 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 23 a. DATE OF DEATH (Mo., Day, Yr.) Mau 11.24 23h: f AT SIGNED{Mo., Day, Yr.) ex 3e a o e Mav12,2017 2 u 0 F W 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) Jennifer L. Sriwn, MD STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Patricia R. Curran Westlawn Cemetery DUE TO, OR AS A CONSEQUENCE OF: P) Congestive Heart Failure DUE TO, OR AS A CONSEQUENCE OF: a) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 23c. TIME OF DEATH 12:05 AM CITY /TOWN 201704387 5a. AGE:. Last Birthday (Yrs.) 85 10b. NAME OF SPOUSE, (First, Middle, Last, Suffix) If wife, give maiden name Michael F Koziol 14a. INFORMANT -NAME Tim Koziol 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN CAUSE OF DEATH (See instructions and examples) 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) z z U 8a. PLACE OF DEATH HOSPi ❑ Inpatient ❑ ER/Outpatient ❑ DOA Sc, CITY OR TOWN Grand Island 9e. APT. NO. 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Helen Jarecke i7 NO b;' UNDER 1 YEAR MOS. DAYS 16b. LICENSE NO. 1092 STANLEY S.ICOOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 2. SEX Female 5c. UNDER 1 DAY HOURS 21 b. IF TRANSPORTATION ❑ Olivet/Operator ❑ Passenger 0 Pedestrian :❑ Other (SpecifY) 25. DID TOBACCO: USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ®'NO ❑ PROBABLY ❑ UNKNOWN ❑ YES 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 MINS. O7 HER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall Grand Island STATE 24a. DATE SIGNED (Mo., Day, Yr.) 9f. ZIP CODE 68803 INJURY 24C, PRONOUNCED DEAD (Mo., Day, Yr.) November 6, 1931 16c. DATE (Mo., Day, Yr.) May 19, 2017 3. DATE OF DEATH (Mo., Day, Yr.) May 11,2017 6. DATE OF BIRTH (Mo., Day, Yr.); onset to death > 1 Year onset to death ❑ YES ® NO 24b. TIME OF DEATH D. Hospice Facility 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Son STATE Nebraska 17b. Zip Code 68801 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) APPROXIMATE INTERVAL onset to death. < 1 Day 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED?. ❑ YES El NO 21c. WAS AN AUTOPSY PERFORMED? 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF .DEATH? ❑ YES ❑ NO ZIP CODE 24d. TIME PRONOUNCED:DEA7) I 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (MR•, Oay, Yr..) May 18, 2017