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P o l �. ",,t ' ` � �`�ii`` w r �'� s , `l 1 e. &Aa.t 1 e t STATE OF NEBRASKA #° 1 , ),/ 11(0, 41 1. DECEDENT'S (First, Middle, Last, Suffix) Thomas L Kovanda 4. CITY AND STA Burwell, Nebraska 7. SOCIAL SECURITY NUMBER 505 -78- 6556 t, FACILITY -NAME Knot Institution, give street and number) Bryan Medical Center West 8c. CITY OR TOWN OF DEATH (Include Zip Code) Lincoln 68502 Ea. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 907 Bell Blvd. Oa. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑Married, butseparated i; ❑ Widowed ❑ Divorced ❑ Unknown 1. FATHER'S -NAME (First, Middle, Last, Suffix) Keith Kovanda 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME (Yes, Na, Or Unk,) NO Mary W Kovanda 5. METHOD OF DISPOSITION ❑ Burial 0 Donation El Cremation ❑ Entombment ❑ Retitoyal ❑ Other (Specify) 7a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)s' All Faiths Funeral Home. 2929 S. Locust Street, Grand Iceland Nebraska in death) _... Sequentially list conditions, if any, leading .to the cause lisle on line a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) {disease or in jury that initiated . t he events raselting et death) : DUE TO OR AS A CONSEQUENCE OF: tAST .. :.; 0. IF;FEMALE: ❑ Not pregnant Within past year ❑. Pregnant at time of death ❑ Not pregnant, bet pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnanf wittiba the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WOR$? 0 YES ❑ NO 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 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 7/28/2017 LINCOLN NEBRASKA E OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 9b. COUNTY Hall 16a. EMBALMER- SIGNATURE Not Embalmed 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Lincoln Cremation Service 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 23a. DATE OF DEATH (Mo., Day, Yr.) July 20, 2017 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH July 21, 2017 03:06 PM 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) Sact in LsfTiiehhane, MD 201705299 STATE OF NEBRASKA - DEPARTMENT OF HEALTH! AND HUMAN SERVICES CERTIFICATE OF DEATH 5a, AGE - Last Birthday (Yrs.) 61 r' b. UNDER 1 YEAR MOS. 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑: ER/Outpatient DOA c. CITY OR TOWN Grand Island DAYS 9e. APT. NO. 2. SEX Male 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Mary W Wright : 12. MOTHER'S -NAME (First, Middle, 1 Shirley Anderson LICENSE NO. Lincoln CAUSE OF DEATH (See instructions and examples) DUE TO, OR AS A CONSEQUENCE OF: b)Acute Diastolic Congestive Heart Failure With Volume Overload 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could net be determined CITY/TOWN 2 5. DID TO COG USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ❑ NO ❑ PROBABLY El UNKNOWN ❑ YES ONO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Sachin Lamichhane, MD, 2300 S 16th St, Lincoln, Nebraska, 68502 GISTRAR'S SIGNATURE ,,.y bj STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 5c. UNDER 1 DAY HOURS 24a. DATE SIGNED (Mo., Day, Yr.) MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Lancaster 9f. ZIP CODE 68801 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, respiratotyarres4 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 CAUSE (Final a)Acute On Chronic Hypoxic And Hypercapneic Respiratory Failure 18, PART II, OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Acute Kidney Injury, Respiratory Arrest At Home, Streptococcal Bacteremia, Severe Sepsis 21b. IF TRANSPORTATION INJURY Driver /Operator ❑ Passenger ❑ Pedestrian ▪ other (Specify) STATE 24c. PRONOUNCED DEAD (Mo., Day, Yr.) ape 3. DATE OF DEATH (Mo., Day, Yr.) July 20, 2017 6. DATE OF BIRTH (Mo., Day, Yr ; September 4, 1955 Maiden Surname) 16c. DATE (Mo., Day; ` Yr.) July 22, 2017 onset to death Days onset to death 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® 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) 24d. TIME PRONOUNCED DEAD 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) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 28b. DATE FILED BY REGISTRAR July 24, 2017 ❑ Hospice Facility 9g. INSIDE CITY LIMITS' ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse STATE Nebraska 17b. Zip: Code 68801 APPROXIMATE: INTERVAL onset to death Days 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® ND ❑3