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( xr. tee__ B. 'E U 2 0 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 8/2/2017 LINCOLN, NEBRASKA 1. DECEDENTS - NAME (First, Middle, Last, Suffix) Douglas Paul Beran 4, CITY AND STATE CO R TERRITORY, OR FOREIGN COUNTRY OF BIRTH 7. SOCIAL SECURITY NUMBER 50770. -0833 Grand Island, Nebraska b. FACILITY -NAME If not Institution, give street and number) 2129 West '10th. Street 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 Rua E t.e -4 i E Nebraska 9d. STREET AND' NUMBER 2129 West 10th Street 1ga. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 0 Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Enter the UNDERLYING CA loisease or iniurytliat innutted <. t he events resulting 1n (oath) LAST.:3. 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death Not pregnantt$ut pregnant within 42 days of death Not pregnant:139t pregnant 43 days to 1 year before death ❑ Unknown if pregnartt Within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 2aa. DP TE OF DEATH (Mo., Day, Yr.) JUN 24, 20.17' 25b. DATE SIGNED (Mo., Day, Yr.) July 25, 2017 I 28a REGISTRAR'S SIGNATURE 194 lokuiltus, STATE OF NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH _I 90. COUN l y Hall 11. FATHER'S -NAME (First, Middle, Last, Suffix) Joseph Beran 1 ; EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unit.) NO 15. METHOD OF DISPOSITION Ed Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal '❑ Other (Specify) 16a. EMBALMER-SIGNATURE Katie M. Smydra Westlawn Cemetery 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island. Nebraska DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: C) DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 2e. DESCRIBE HOW INJURY OCCURRED 22d.INJURY ATWORK? YES ..❑ NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Jay 0. Anderson, MD 25. DID TOBACCD USE CONTRIBUTE TO THE DEATH? ® YES CI NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jay C, Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 23c. TIME OF DEATH 05:06 PM 201705881 5a. AGE - Last Birthday (Yrs.) CITY/TOWN 65 16d. CEMETERY, CREMATORY OR OTHER LOCATION Sb. UNDER 1 YEAR MOS. DAYS 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient DOA 9c, CITY OR TOWN Grand Island STANLEY S. OPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 8d. COUNTY OF DEATH Hall 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 9f. ZIP CODE 68803 awl eathg 3. DATE OF DEATH (Mo., Day, Yr.) July 24, 2017 6. DATE OF BIRTH (Mo., Day, Yr.);, July 3, 1952 OTHER ❑ Nursing Home /LTC Decedent's Home ❑ Other (Specify) Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Cynthia Ann Mossman 14a. INFORMANT-NAME Cynthia Ann Beran CAUSE OF DEATH (See instructions and examples) $. PART I. Enter tire; chain of events- - diseases, Injuries, or complications -that directly caused the death. DO NOT entertermmal events such as cardiac arrest, respiratory arrest or ventritular 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) Adenocarcinoma Of Lung Metastatic To Bone And Liver G.aeas2 or can d; .an rasrr:aNg i death) Sequentially fist conditmha, if b) any, leading to the cause lis on line a. 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Coronary Artery Disease, Hypertension, Type 2 Diabetes, Gout, Hyperlipidemia 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide 0 Could not be determined 1 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Lucille Fortin 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 16b. LICENSE NO. 1454 CITY / TOWN Grand Island 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED ?' © Driver /Operator ❑ Passenger ❑ YES ®NO 0 Pedestrian Other (Specify) STA?' 24a. DATE SIGNED (Mo., Day, Yr.) n y ¢ g Z 02o z o' F K : U 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES El NO 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAI 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) 28b. DATE FILED BY REGISTRAR (Aga., Day, Yr.) July 31, 2017 onset to death onset to death onset t 24b. TIME OF DEATH 0 Hospice Facility 9g. INSIDE CITY LIMITS ❑ YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr.) July 28, 2017 STATE Nebraska 17b, Zip Cod 68801 APPROXIMATE INTERVAL onset to dedth Years 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO . ZIF'E 26b. WAS CONSENT GRANTED Not Applicable if 26a is NO ❑ YES ❑ NO