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STATE OF NEBRASKA II E O V 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 8/1712017 LINCOLN, NEBRASKA 1, DECEDENTS -NAME (First, Middle, Last, Suffix) Gregg Alan Bostelman 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Fairbury, Nebraska 7. SOCIAL SECURITY NUMBER 507 -72- 6840.. 8b. FACILITY -NAME (If not Institution, give street and number) 1711 S pring !Road 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island: 68801 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 1711 Spring Road 113a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married ❑ Married, but separated !0 Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Dwayne Bostelman 13 ..EVER IN U.S. ARMED FARCES? Give dates of service if Yes. 14a. INFORMANT -NAME {Yes No, or Unk.) No Joni Kae Bostelman 15. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE ❑ Burial ❑ Donation E Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) !!! ADfel Funeral Home, 1123 W. 2nd, Grand Island. Nebraska .PA IMMEDIATE CAUSE (Final disease or condition resulting odeath) Sequentially list coiditions, if ny, leading t° the tause listed on line a. Enter the UNDERLYING CAUSE (disease er injury tli81L Initiated ?. ..._.. . ........ the events redu sukmg ; m ant death - 1). IF FEMALE: ❑ Not pregnant within pain year ❑ Pregnant at time of death 0 Not pregnant bid pregnant within 42 days of death fl Net pregnant,ttut pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 22a. DATE OF INJURY (Mo.,. Day, .Yr.) I22b. TIME OFINJURY d. INJ URY AT:w ?' ❑YES ❑NO 22t. LOCATION OF INJURY - STREET & NUMBER, APT.NO. . DATE OF DEATH (Mo., Day, Yr.) i w AURUSt 7, 2 T. Y 2 8b DATE SIGNED ' (Mo.; Day, Yr.) 23c. TIME OF DEATH g r; : August 9, 2017 11:37 PM c 3d. To the best of my knowledge, death occurred at the time, date and place u and due to the cause(s) stated. (Signature and Title) Ryan Ramaekers, MD . DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES NO ❑ PROBABLY ❑ UNKNOWN ❑ YES E' NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ryan Ram. aekers, MD, 2116 W. Faidley Avenue, Grand Island, Nebraska, 68803 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1 9b. COUNTY 9c. CITY OR TOWN Hall Grand Island Not Embalmed 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services Gibbon a) Lymphoma, Metastatic DUE TO, OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 22e. DESCRIBE HOW INJURY OCCURRED CAUSE OF DEATH (See instructions and examples) 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 201706034 5a. AGE - Last Birthday CITY/TOWN (Yr$:) MOS. DAYS 63 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA c t z .° U d w 2 O 8 z ° O 5b... UNDER 1 YEAR 9e. APT. NO. 24a. DATE SIGNED (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? awl STANLEY S.WCOOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 2. SEX Male &b. LICENSE NO. 5c. UNDER 1 DAY HOURS MINS. 6. DATE OF BIRTH OTHER ❑ Nursing Home /LTC E Decedent's Home ❑ Other (Specify) I 8d. COUNTY OF DEATH Hall CITY / TOWN 9f. ZIP CODE 68801 J. Enter the Chain of events- - diseases, injuries, or complications -that directly caused the death. DO NOT enter ter urinal events such as cardiac arrest, piratory rarest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on 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 1. 21b. IF TRANSPORTATION INJURY ❑ Dnver /Operator ❑ Passenger ❑ Pedestrian ❑ Qther (Specify) STATE 24C. PRONOUNCED DEAD (Mo., Day, Yr.) 3. DATE OF DEATH (Mo., Day, Yr.) August 7, 2017 December 27, 1953 lob. NAME OF SPOUSE', (First, Middle, Last, Suffix) If wife, give maiden name Joni Kae Smith I ' 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Avis Pingel August 9, 2017 onset to death 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E NO ❑YES [3 Na', 1 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24b. TIME OF DEATH 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO DYES 24d. TIME PRONOUNCED'DEAD 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) 28b. DATE FILED BY REGISTRAR {Mo„ Day, Yr.) August 15, 2017 ay, Yr ❑ Hospice Facility 9g. INSIDE CITY LIMITS E YES ❑ NO 14b. RELATIONSHIP T0 DECEDENT Spouse 16c. DATE (Mo., Day Yr.) STATE •Nebraska 17b. Zip Code 68801 APPROXIMATE INTERVA onset to death.. 2 Years 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ENO` 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OP DEATH? ZIP CODE ❑