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Pk STATE OF NEBRASKA 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 201707379 STANLEY S. DOPER ASSISTANT STATE REGISTRAR 5/31/2017 DEPARTMENT HEALTH AND HUMAN SERVICES LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Duane Donald Langan 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH w v Platte Center, Nebraska 7. SOCIAL SECURITY NUMBER 507 -30 -2187 8b. FACILITY -NAME (If not institution, give street and number) Wedgewood Care Center 9d. STREET AND NUM 107 W. Ashton 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 a. RESIDENCE-STATE Nebraska R 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. 14a. INFORMANT- NAME (Yes, No, or unk.) Yes 1951-1955 Mike Lachnit 15. METHOD OF DISPOSITION 16a. EMBALMER- SIGNATURE ❑ Burial El Donation Beniamin Hall ❑ Cremation 0 Entombment - 16d. CEMETERY, CREMATORY OR OTHER LOCATION ❑ Removal :❑ Other (Specify) Sequel tiatly het sar+dmang d .; any, - leading to cauSh hated _.. .. ...... .____ on line a. - - Enter the UNDERLYING CAUSE (diseaetk ar ipjury that Imtrated: the eventaresulting: in death) LAST' 22a. DATE OF INJURY (Mo., Day, Yr.) 22 d. INJURY AT.WORK? ❑YES D NCI William Landis, MD 9b. COUNTY Hall Nebraska Anatomical Board !' DUE TO, OR AS A CONSEQUENCE OF: b) Hypertension DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 20. IF FEMALE: ❑ Not pregnant siithin past year ❑ Pregnant at time of death Not pregnant,,:but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ UnkrtaWn if pregnant within the past year 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET 8, NUMBER, APT.NO. CITY/TOWN . DATE OF DEATH (Mo., Day, Yr.) May 12, 2017 6 DATE S(GNED (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 cause(s) stated. (Signature and Title) 5a. AGE! - Last Birthday 5b. UNDER 1 YEAR (Yrs.) 85 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand < Island 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ could' not be determined 25 ?DID TOBACCO USE fO NTRIBUTETO THE DEATH? 2 YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Will am Landis, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803 28a. REGISTRARS SIGNATURE jej- 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY HOURS 7a. 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 CAUSE OF DEATH (See instructions, and examples) 1617, LICENSE NO. 1305 CITY/TOWN Omaha MINS. 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68803 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Minnie Kamm la. PART I. Enter the l'chain ofevents- - diseases, injuries, or complications -that directly caused the death, DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventrifutar 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) Chronic Obstructive Lung Disease disease or condition resulting 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Diabetes Mellitus Type 2, lschemic Heart Disease, Abdominal Aortic Aneurysm 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger 0 Pedestrian ❑ Other (Specify) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 3. DATE OF DEATH (Mo., Day, Yr.) May 12, 2017 6. DATE OF BIRTH (MO. Day, Yr :1 June 30, 1931 OTHER ® Nursing Home /LTC ❑ Hospice Facility ❑ Decedent's Home ❑ Other (Specify) 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name 9g. INSIDE CITY LIMIT ❑ YES ❑ NO 14b. RELATIONSHIP: 0 DECEDENT .. Nephew 16c. DATE (Mo., Day, Yr.) May 15, 2017 STATE Nebraska 17b. zip Cod 68801 68198 -6395 A P P R OX /M A TE I NTERVA L. onset to death 5 Years onset to death:: 10 Years onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑YES: NO 21c. WAS AN AUTOPSY PERFQ ❑ YES El 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) .TATE ZIP CODE' 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 2.4c. PRONOUNCED DEAD (Mo., Day, Yr. 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 (MO., Day, Yr.)'. May 18, 2017