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ZAAJ ION to' 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 1/16/2018 LINCOLN, NEBRASKA 201890965; STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1 STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 'awn r Q (3 W cc 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Iola Mae Block 4. CITY ND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Merrick County, Nebraska 7. SOCIAL SECURITY NUMBER 508 -1 -9293 Bb. FACILITY -NAME Ilf not Institution, give street and number) 115 South Buffalo Road 23a. DATE OF DEATH (Mo., Day, Yr.) • January 6, 2018 & w 23b. GATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH I 0 z January 8, 2018 05:05 PM Z O 3d. To the best of my knowledge, death occurred at the time, date and place 2 c and due to the cause(*) stated. (Signature and Title) Kenneth Vettel, MD 25, DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 5a. AGE - Last Birthday (Yrs.) MOS. 93 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 26a. HAS ORGAN OR TISSUE DONATION B ❑ YES El NO Sb. UNDER 1 YEAR DAYS EN CONSIDERED? 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. OTHER ❑ Nursing Home /LTC El Decedent's Home ❑ Other (Specify) 24a, SATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 3. DATE OF DEATH (Mo., Day, Yr.) January 6, 2018 6. DATE OF BIRTH (Mo, Day, Yr.) November 29, 1924 ❑ Hospice Facility 8c. CITY OR TOWN OF DEATH (Include Zip Code) Doniphan ; 68832 [ 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE 9b. COUNTY Nebraska Hall 9c. CITY OR TOWN Doniphan 9d. STREET AND NUMBER 115 South Buffalo Road 9e. APT. NO. 9f. ZIP CODE 68832 9g. INSIDE CITY LIMITS ❑ YES ® NO 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated El Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Richard Block 11, FATHER'S -NAME (First, Middle, Last, Suffix) William Lutrell 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Bedie Bell 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME (Yes, No, orUnk.) No Carol Staley 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OP : DISPOSITION 16a. EMBALMER - SIGNATURE ❑ Burial ❑ Donation Derek Apfel I 16b. LICENSE NO. 1240 16c. DATE (Me., Day, Yr,) January 10, 2018 ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION Rosedale Cemetery CITY /TOWN Doniphan STATE Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Arfel Funeral Home, 1123 W. 2nd. Grand Island. Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enterthe`, of events- -diseases, injuries, or complications -that directly caused the death. 00 NOT enter terminal events such as cardiac arrest, respiratory arrest, 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) Cardiopulmonary Arrest disease or condition resulting APPROXIMATE INTERVAL onset to death Acute in death) Sequentially list cpnditIoPe, d any, leading to the eause listed DUE TO, OR AS A CONSEQUENCE OF: b) Dementia onset to death 1 -2 Years Enter the UNDERLYING CAUSE • (disease or injury that Imtiat4d. the exam$ resuaiiig. in death) LAST DUE TO, OR AS A CONSEQUENCE OF: c) Atrial Fibrillation onset to death > 5 Years DUE TO, OR AS A CONSEQUENCE OF: d)Pulmonary Vascular Disease onset to death > 5 Years 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. HTft. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 20. W FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Npt pregnant, but Pregnant within 42 days of death Not pregnant,'. but pregnant 43 days to 1 year before death ❑ Unknown 0 pregnant within the past year 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger Pedestrian 0 Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE' CAUSE OF DEATH? ❑ YES ❑! NO 22a. DATE OF INJURY (Mo., Day, Yr.) I 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT, WORK? ; 122e. DESCRIBE HOW INJURY OCCURRED ❑ YES Q NO II 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN 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 Tide) 26b. WAS CONSENT GRANTED ? Not Applicable if 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Kenneth Vettel, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE / Omelfixot. 28b. DATE FILED BY REGISTRAR (MO., Day, Yr.) January 10, 2018