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t 7 /✓ 40W i i" ':eAle 1wa STATE OF NEBRASKA :7• 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Donald Con Enck SR 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 506 -28 -1277 w . 8b. FACILITY-NAME (If not Institution, give street and number) 0 Veterans Affairs Medical. Center 5a. AGE - Last Birthday 5b. U (Yrs.) 82 8a. PLACE OF DEATH HOSPITAL Q( Inpatient ER/Outpatient ❑ DOA MOS. 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand, Island 68803. 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9d. STREET AND NUMBER 714 Pine St 9e. APT. NO. 10a. MARITAL STATUS AT. TIME OF DEATH ❑ Married ❑ Never Married Married, bit separated ` ,' ® Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Ward Enck 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Bonita Corl E 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or (MIC,) Yes 05/04/ 957-08/01/1962 15. METHOD OF DISPOSITION F ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Not Embalmed 14a. INFORMANT -NAME Deb Petersen 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Memorial Park Crematory 7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston- Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska DER 1 YEAR 5c. UNDER 1 DAY DAYS 2. SEX Male 1615 LICENSE NO. HOURS 10b. NAME OF SPOUSE (First, Middle, Last, Suffix Elizabeth Dittman wife, give maiden name, CITY /TOWN Grand Island CAUSE OF DEATH (See instructions and examples) MINS. OTHER ❑ Nursing Home /LTC ❑ Cacedent's Nor , ❑ Other (Specify) 9f. ZIP CODE 68803 3. DATE OF DEATH (Mo., Day, Yr.) July 28, 2017 6. DATE OF BIRTH (MO.,. Day Yh) December 19, 1934 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Daughter 16c. DATE (Mo., Day, Yr.) August 1, 2017 STATE Nebraska 17b. Zip Code 68803 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 8/10/2017 LINCOLN, NEBRASKA PART). Enter the Chain of events-diseases, injuries, or complications -that directly caused the death. DO NOT enterterrninal events such as cardiac arrest, respiratory anest, or ventricular 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) Gastrointestinal Bleeding disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b)presumed Gastrointestinal Malignancy': any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE {disease or Injury that initiated?: the events resumng in death) . DUE TO OR AS A CONSEQUENCE OF: LAST 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Refusal Of Transfusion And Agressive Interventions, COPD, 20. IFS FEMALE ❑ Not pregnant within past year ❑ Pregnant at time of death Not pregnant .,.but pregnant within 42 days of death ❑ Not pregnant 6411 pregnanr days to 1 year before death ❑unknown it pregnant within the past year 225. DATE OF INJURY (Mo., Day, Yr.) 22d. (NJUR.Y AT WOR ❑YES C}NO DUE TO, OR AS A CONSEQUENCE OF: C) d) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 22a. DATE OF DEATH (Mo., Day, Yr.) 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH July 31, 2017 07:11 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) haven S. Lawrence, MD 28a REGISTRAR " S SIGNATURE 201708003 STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) CITY /TOWN 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BE ❑ YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Shawrt S. Lawrence, MD, 223 South E St, Broken Bow, Nebraska, 68822 21b. IF TRANSPORTATiON INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) STATE coop onset to death onset to death onset tied ath 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES gi NO ' 21c. WAS AN AUTOPSY PERFORMED? ❑YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH APPROXIMATE INTERVAL onset to death 1 Year 24c. 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) N CONSIDERED? 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ 28b. DATE FILED BY REGISTRA August 3, 2017 NO (Me., Day, Yr.)