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STATE OF NEBRASKA ate .., , i 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 5/31/2017 LINCOLN, NEBRASKA 201705950 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES LL a 15 i W U E 0 0 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Duane Donald Langan 4 . CITY.AND STATE OR Platte Center, Nebraska RRITORY, OR FOREIGN COUNTRY OF BIRTH 7. SOCIAL SECURITY NUMBER. 507 -30 -2187 8b. FACILITY -NAME Of not Institution, give street and number) Wedgewood, Care Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE-STATE Nebraska 9d. STREET AND NUMBER 107 W. Ashton 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ® Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Edward Langan 13, EVER IN U.S, ARMED FORCES? Give dates of service if Yes. (Yee, NO, or Urtk -) Yes ':1951 -1955 15. METHOD OF:AISPOSITION ❑ Burial Donation ❑ Cremation ❑ Entombment ❑ Refnoval Q Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island. Nebraska for Nebraska Anatomical Board. 986395 Nebraska Medical Center, Omaha. Nebraska IMMEDIATE CAUSE(Final a) Chronic Obstructive Lung Disease disease or condition resulting and ath) Sequentially list conditions, if any, leading tt, the yause listed. on line a::: Enter the UNDERLYING. CAUSE (disease injury that inntated the events resu ltlnfj,in death) LAST; 20. IF FEMALE: ❑ Not pregnant within past year 0 Pregnant at time of death ❑ Not pregnant,,but pregnant within 42 days of death Not pregnant, t!ut pfagnant:Aa days to 1 year before death 0 Unknown ifpfegnafawithinthe past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT INORIEP ::: • DID TOBACCO USE CONTRIBUTE TO THE DEATH? ®'YES ❑ NO ❑ PROBABLY ❑ UNKNOWN . DATE OF tEATH (Mo., Day, Yr.) r' 1'&V 12 2317 5a. AGE - Last Birthday (Yrs.) 85 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Beniamin Hall DUE TO, OR AS A CONSEQUENCE OF: b) Hypertension b, DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH May 16, 2017 10:00 PM 3d, To the best of my knowledge, death occurred at the time, date and place and due to the causels) stated. (Signature and Title) Williarn Landis, MD 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 28a. REGISTRAR SIGNATURE ,6 I� J�cJ 6b. UNDER 1 YEAR MOS. DAYS 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) May 12, 2017 6. DATE OF BIRTH (Me. June 30, 1931 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient 0 ER/Outpatient ❑ DOA OTHER ® Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) Hospice Facility 8d. COUNTY OF DEATH Hall Sc. CITY OR TOWN Grand Island 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS" II YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Minnie Kamm 14a. INFORMANT- NAME Mike Lachnit 16b. LICENSE NO. 1305 14b. RELATIONSHIP TO DECEDENT 16c. DATE (Mo., Day, Yr.) May 15, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN Nebraska Anatomical Board Omaha STATE Nebraska CAUSE OF DEATH (See instructions and examples) IS, PAIIT 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 unreal, of ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line;: Add additional lines if necessary. IMMEDIATE CAUSE: 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Diabetes Mellitus Type 2, lschemic Heart Disease, Abdominal Aortic Aneurysm 21b. IF TRANSPORTATION INJURY ❑ Denier/Operator ❑ Passenger 0 Pedestrian 0 Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr. 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES El NO 17b.zip "Code 68801 68198 -6395 APPROXIMATE IN onset to death 5 Years onset to death :: 10 Years 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) 28b. DATE FILED BY REGISTRAR (Mo., Day, May 18, 2017 DUE TO, OR AS A CONSEQUENCE OF: C) onset to death DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? OYES NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES Ii NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22b. TIME OF INJURY 122c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print William Landis, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803 ) CO O