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■,v1 k t a ,: , esv pkxc ... �iXi STATE OF NEBRASKA WHEN ' THI -' 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 6/7/2017 LINCOLN, NEBRASKA STANLEY S. 20170655 7 DEPARTMENT HEALTH AND REGISTRAR HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Raymond Rolland Quandt 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Gra 9d »Island, Nebraska 7. SOCIAL SECURITY NUMBER 505 -52 -1322 . FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 9e, RESIDENCE -STATE Nebraska 113a, MARITAL STATUS AT TIME OF DEATH EI Married ❑ Never Married ❑ Married, butseparated ❑ Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S.; ARMED FORCES? Give dates of service if Yes. (Yes, No, or Un Yes 03/05/1956- 10/07/1957 16a. EMBALMER - SIGNATURE 15. METHQD OF DISPOSITI€N Burial [} Donation ❑ Cremation ❑ Entombment ❑ Removal Q Other(Specify) Enter the UNDERLYING CAUSE c) (disease W Ehlurythat inhfafetl the events resuItieg;In death) LAST i'. 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ NM pregnant, bu Rragnent within 42 days of death ❑ •Not pregnam, but pregnant43 days to 1 year before death ❑ Unknown if pregnant withinthe past year 22a. DATE OF INJURY (Mo., Day, Yr.) !2d. ENJURYAT.. IIORK? YES ❑ NO 23a. DATE OF DEATH (Mo., Day, Yr.) W May 30.2017 2S DATE SIGNED (Mo., Day, Yr.) May 31, 2017 DUE TO, OR AS A CONSEQUENCE OF: 23c. TIME OF DEATH 10:22 AM o 0 u. a 3d. To the best of my knowledge, death occurred at the time, date and place 9 and due to the cause(s) stated. (Signature and Title) F. ! J ane A. McDonald, MD 5a. AGE - Last Birthday (Yrs.) 8 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9b. COUNTY Hall 9d. STREET NUMBER' 8937 N. Quandt Rd Katie M. Smydra 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES El NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print , Jane A. McDonald MD, 800 N Alpha Street, Grand Island, Nebraska, 68803 5b. UNDER 1 YEAR MOS. DAYS 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) May 30, 2017 6. DATE OF BIRTH (MO „ >Day, Yf.) July 17, 1935 8a. PLACE OF DEATH HOSPITAL © Inpatient OTHER ❑ Nursing Home /LTC ❑ ERlOutpatient ❑ Decedent's Home 0 DOA ❑ Other (Specify) ❑ Hospice Facility 9c, CITY OR ^TOWN Grand Island 9e. APT. NO. 9f. ZIP CODE 68801 10b. NAME OFi SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Carol Ann Lowry 11. FATHER'S -NAME (First, Middle, Last, Suffix) :: 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Laura Scherzberg Walter Quandt 14a. INFORMANT-NAME Carol Ann Quandt 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State# All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Hypertension,chronlc Atrial Fibrillation, History Of Chronic Obstructive Lung Disease, Diabetes, Aortic Valve Replacement, anti- thrombin ;3 Deficiency, Sleep Apnea 8d. COUNTY OF DEATH Hall 16b. LICENSE NO. 1454 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger Pedestrian ❑ Other(Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. 'PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES Ej NO 9g. INSIDE CITY LIMITS ❑ YES ® NO 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Da Yr.)' June 3, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION Wiegert Cemetery CITY / TOWN Grand Island STATE Nebraska 17b Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 1a. PART f. Enter the chain Of events- diseases, injuries, or complications -that directly caused the death. 00 NOT enterterminat events such as cardiac arrest, respiratory arttOt, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Inc. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure, pneumonia, Heart Failure disease or condition resulting En; death) APPROXIMATEINTERVAL: onset to death 5 Days Sequentially list eohdttioneE.. any, leading to the cause fisted on line a DUE TO, OR AS A CONSEQUENCE OF: b)Coronary artery Disease, Chronic Obstructive Lung Disease, Oxygen Dependent onset tO dea Years onset to death DUE TO, OR AS A CONSEQUENCE OF: d) onset t death. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES RI NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑YES ❑NO 22b. TIME OF INJURY 22c. 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. crryrrOWN STATE ZIP CODE 24b. TIME OF DEATH 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 ❑ NO 28b. DATE FILED BY REGISTRAR (MG.,;Day, Yr.) !' June 2, 2017