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STATE OF NEBRASKA a h43 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 7/11/2017 LINCOLN, NEBRASKA 207©4847 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Coe STANLEY S.LOOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES Q U " W CC G J 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Lee Roland Cohn 4. CITY AND STATE OR T CottonwoodSprings, Nebraska RITORY, OR FOREIGN COUNTRY OF BIRTH 7. SOCIAL SECURITY NUMBER 508 -40- 4124 8b. FACILITY - NAME (If not Institution, give street and number) CHf Health St. Elizabeth 5a, AGE Last Birthday (Yrs.) 84 Sc. CITY OR TOWN OF DEATH (Include Zip Code) Lincoln 68510 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 1224 W. 9th St. 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, butseparatett ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) I ' 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Harry Cohn Eva Towers 13, EVER IN U.S.' ARMED FORCES? Give dates of service if Yes. (Yea, No, or Unk.) YeS 09/21/1955- 06/25/1957 15. METHOD OF DISPOSITION ❑ Burial 0 Donation Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Not Embalmed Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Laurel EvaLyn Bostock -Lewis 14a. INFORMANT -NAME Laurel EvaLyn Cohn 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon STATE Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska CAUSE OF DEATH (See instructions and examples) 1a. PART I. Enter they chain of events -- diseases, injuries, or complications -that directly caused the death, DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventrieul*r fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Distress APPROXIMATEN DUE TO, OR AS A CONSEQUENCE OF: b) in death) Sequentially Fist conditions, If any leading to the cause listed on line a. onset to death DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or in)ury )Cal initiated the events resulting in death) LAST DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Hist¢ry of Spinal Stenosis; Chronic Infections; Atrial Fibrillation; Diabetes; Coronary Artery Disease; Hypertension; Stroke; And (-irTlited Mobitliy 20. IF FEMALE: :: ❑ Not pregnant within year ❑ Pregnant at time of death 0 Not pregnant; Out pregnant within 42 days of death ❑ •Ntit pregnant, but pregnant :43 days to 1 year before death ❑ Unknown If pregnant wi the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? YES ONO 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 5 II< 25a, DATE OF DEATH (Mo., Day, Yr.) 23 b. DATE SIGNED (Mo., Day, Yr.) C u z . e, 0 3d. To the best of my knovAedge, death occurred at the time, date and place 2 2 and due to the cause(s) stated. (Signature and Title) 22b. TIME OF INJURY 5. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES 0 NO ❑ PROBABLY ® UNKNOWN 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 23c. TIME OF DEATH 5b. UNDER 1 YEAR MOS. DAYS 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH HOSPITAL 0 Inpatient ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) Sd. COUNTY OF DEATH Lancaster 9c. CITY OR TOWN Grand Island 16b. LICENSE NO. 21b. IF. TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger 0 Pedestrian Other (Specify) 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED CITY/TOWN STATE • 21P CODE 248. DATE SIGNED (Mo., Day, Yr.) Juty 3, 2017 24c. PRONOUNCED DEAD (Mo., Day, Yr.) June 30,2017 26a. HAS ORGAN' OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 9f. ZIP CODE 68801 3. DATE OF DEATH (Mo., Day, Yr.) June 30, 2017 May 17, 1933 6. DATE OF BIRTH (Mo., Day, Yr.) 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO, DECEDENT Wife 16c. DATE (Mo., Day, Yr.) July 5, 2017 17b. Zip Code 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? CONTACTED? ❑ YES taI NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? E YES L..1 NO 24b. TIME OF DEATH 03:58 PM 24d. TIME PRONOUNCED DEAD 03:58 PM 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 Title) Joe Kelly, Lancaster County Attorney 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Joe Kelly, Lancaster County Attorney, 575 South 10th St., 4th Floor, Lincoln, Nebraska, 68508 1 aa; REGISTRR'S SIGNATURE ^ & J 28b. DATE FILED BY REGISTRAR (Mo July 6, 2017