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,c \ Xj;' Je99 ardA, "i i4 , dnM.'1 f.. STATE OF NEBRASKA Mil); WAWAorttmtar 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 8/18/2017 LINCOLN NEBRASKA S egeeinially list coflt dons, if any, leading to titre cause Ilsted Enter the UNDERLYING CAUSE (disease or 0filfY Ost 1fRlated: tha events resuitinirl death) . DUE TO, OR AS A CONSEQUENCE OF: LAST::; 20. IF FEMALE: ❑ Not pregnant within past year ❑- Pregnant at time of death CI Not pregnant, Out pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Upknmve if pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 2 22f INJURY AT WORK ❑ YES ❑NO DUE TO, OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: c) d) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED LOCATION OF INJURY STREET & NUMBER, APT.NO. 23a. DATE OF DEATH (Mo., Day, Yr.) /%04 Z4 Y, 2017 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH August 9, 2017 10:47 AM 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) Shawn S. Lawrence, MD 201706720 CITY/TOWN 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined ffff�» `o 0 Pedestrian Other (Specify) STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. OOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES it 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, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one rause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Metastatic Lung Adenocarcinoma disease ar cor4it u„ reav +iny iR: death) : '::i` " 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Chronic Obstructive Pulmonary Disease O YES ® ❑ Passenger STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) onset to death 1. DECEDENTS -NAME (First, Middle, Last, Suffix) James William Lilienthal 4. ::CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 811. FACILITY -NAME (If not Institution, give street and number) Veterans Affairs Medical Center Et 8c. CITY OR TOWN OF DEATH (Include Zip Code) ▪ Grand Island 68803 pC - 9a. RESIDENCE-STATE w Nebraska LL 9d. STREET AND NUMBER >, 1008 W. 12th Street .0 Ot 7. SOCIAL SECURITY NUMBER 505-58 -0942 . 9b. COUNTY Hall 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated; ® Widowed ❑ Divorced ❑ Unknown Middle, Last, Suffix) 11. FATHER'S -NAME (First, Rov Lilienthal 13. EVER(N U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No or Unk,) Yes 'i 05/18/1964-05/17/1968 15. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE ❑ Burial 0 Donation ® Cremation ❑ Entombment ❑ Removal !❑ Other` (Specify) Not Embalmed 5a. AGE - Last Birt (Yrs.) 73 day lob. NAME OF SPOUSE', (First, Mary Jane Gardner 14a. INFORMANT -NAME Jennifer Lilientha 5b. UNDER 1 YEAR MOS. DAYS 8a. PLACE OF DEATH HOSPITAL Q Inpatient r.1 rR,Outnatisht ❑ DOA 9e. APT. NO. CAUSE OF DEATH (See instuctions and examples) 2. SEX Male 5c. UNDER 1 DAY HOURS 1 12. MOTHER'S -NAME (First, Middle, Elsie Luth MINS. OTHER ❑ Nursing Home/LTC r-i Deaeder•.t's Home ❑ Other (Specify) 9f. ZIP CODE 68801 16b. NO. 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska 3. DATE OF DEATH (Mo., Day, Yr.) August 8, 2017 6. DATE OF BIRTH (Mo., Day, Yr.) August 18, 1943 Middle, Last, Suffix) If wife, give maiden name Maiden Surname) ❑ Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 9g. INSIDE CITY 'LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT 16c. DATE (Mo., Day, Yr.) August 11, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE Nebraska 17b.::20 Code 68801 • APPROXIMATE :INTERVAL onset to death 8 Months 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? is ❑ Driver/Operator 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? O YES ❑NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) Z a. REGISTRAR SIGNATURE 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) 25, Dl0 TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN DYES ] NO Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Shawn S. Lawrence, MD, 223 South E St, Broken Bow, Nebraska, 68822 28b. DATE FILED BY REGISTRAR tMo„ pay, Yr.) August 14, 2017 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD