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SA r. fre �� , a�,?d Ytrib 1,312.2194W • iaSihrtifive 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 2/5/2218 LINCOL , NEBRASKA 201801611 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 0 v w 5 J a > 4, m 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Lloyd Dale Colfack 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 506 -22 -5228 8b. FACILITY -NAME (If not Institution, give street and number) Grand Island Lakeview Care & Rehabilitation Center 5a. AGE !- Last Birthday (Yrs.) 90 MOS. DAYS Sb. UNDER 1 YEAR 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Vernon Frederick Colfack 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 04/06/1945- 07/17/1946 15. METHOD OF DISPOSITION Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal Q Other (Specify) IMMEDIATE CAUSE (Final disease or condition resulting in death) • Sequentially list ponditio any leading to the cause li tttt Enter the UNDERLYING CAUSE (disease or Injury that initiated . the events reaching in death) -, LAST 22a. DATE OF INJURY (Mo., Day, Yr.) 22d.INJURY ATWORK? ❑YES ONO } 23b. DATE SIGNED (Mo., Day, Yr.) E z November 13, 2017 y 4 o a V e. 16d. CEMETERY, CREMATORY OR OTHER LOCATION Grand Island City Cemetery 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 within past year ❑ Pregnant at time of death ❑ Nfepregnant„but pregrlarn wit hin 42 days of death ❑ blot Pregnant, bur pregnant 43 days to 1 year before death ❑ tjn own if pregnant Within the past year 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 23a. DATE OF DEATH (Mo., Day, Yr.) November 1, 2 23c. TIME OF DEATH 08:47 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) GarY: :Settle, MD 25. DID TOBACCO use CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined CITY /TOWN 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1021 N Alpha 106, NAME OF SPOUSE (Firs He)en Irene 12. MOTHER'S -NAME (First, Middle, Nettie Boardman 14a. INFORMANT- NAME Helen Irene Colfack 16a. EMBALMER- SIGNATURE Matthew T. Myers 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston - Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska CAUSE OF DEATH (See instructions and examples) 18. PART I. Entetdia:chain of events- -diseases, injuries, or complications -that directly caused the.'. death. DO NOT entertennlnal events such as cardiac arrest, respiratory arteSt, of +lentiicular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: a) Dementia 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in P Congestive Heart Failure 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Gary Settje, MD, :2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 REGISTRAR'S SIGNATURE 16 -128a. 21b. IF TRANSPORTATION INJURY Driver /Operator ❑ Passenger Pedestrian 0 Other (Specify) 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD ; 24e. On the basis of examination and /or investiga ion, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Tide) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES Ea NO 24a, DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 5c. UNDER 1 DAY 9e. APT. NO. 2. SEX Male HOURS MINS. OTHER 1/0 Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 16b. LICENSE NO. 1411 CITY / TOWN Grand Island STATE 3. DATE OF DEATH (Mo., Day, Yr.) November 1, 2017 6. DATE OF BIRTH (Ma., Day, Yr) March 3, 1927 9f. ZIP CODE 68801 Middle, Last, Suffix) If wife, give maiden name Maiden Surname) ❑ Hospice Facility 9g. INSIDE CITY LIMITS ❑ YES ® NO 14b. RELATIONSHIP.; TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr ) November 6,2017 STATE Nebraska 17b, zip Code 68803 APPROXIMATE II onset to death 1 Month onset ao death` 10 Years onset to death onset to death ERVAL ART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ! ® NO 21c. WAS AN AUTOPSYPERFORMED? ❑YES al NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? ❑ YES ❑' NO ZIP CODE 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑'YES ❑ NO 28b. DATE FILED BY REGISTRAR (MO„ Day, Yr.) November 14, 2017