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iaS l if t a p Veto, STATE OF NEBRASKA d/ Y ,i � rttrtetu 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 201802555 12/5/2017 LINCOLN, NEBRASKA 1, DECEDENT'S-NAME (First, Middle, Last, Suffix) Randall JoseQh Bohnart 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 507 -80 -8623 8b. FACILITY -NAME (If not Institution, give street and number) 25. Pioneer Blvd 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 9a. RESIDENCE -STATE Nebraska 94. STREET AND NUMBER 2526 Pioneer Blvd 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑:Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Andrew Collins Bohnart 13. EVER IN U.S. ARMED FORCES? (Yes, No, or link.) NO Give dates of service if Yes. 15. METHOD OF DISPOSITION ❑ ° Burial ❑ Donation 0 Cremation 0 Entombment ❑'Removal ❑ Other (Specify) IMMEDIATE CAUSE (Final in death) Segtreetially fist Conditions, if e the se ... any, leaning to me : " cause listed Brie a. Enter the UNDERLYING CAUSE (disease "'Mere teat initiated the livens resulting in death) LAST 20.1FFEMALE: .. 0 Not pregnant within past year 0 Pregnant at time of death ❑ Not pregnant,but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to i year before death • 0. Unknown it pregnant within the past year 22a, DATE OF INJURY (Mo., Day, Yr.) 2d, INJURY AT WORK? ❑ YES [{ No 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 23a. DATE OF DEATH (Mo., Day, Yr.) November 28, 2017 3b. DATE SIGNED (Mo., Day, Yr.) November 29, 2017 25.O(D TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ]NO ❑ PROBABLY ❑ UNKNOWN 5a. AGE - Last Birthday (Yrs.) 62 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Not Embalmed 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services DUE TO, OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 23c. TIME OF DEATH 06:23 PM 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(S) stated. (Signature and Title) Steven Husen, MD CITY /TOWN 5b. UNDER 1 YEAR MOS. 9c. CITY OR TOWN Grand Island 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a REGISTRAR SSIGNATURE /j ) - alli DAYS HOURS 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER ❑ ER/Outpatient ❑ DOR 8d. COUNTY OF DEATH Hall 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY MINS. 3. DATE OF DEATH (Mo., Day, Yr.) November 28, 2017 6. DATE OF BIRTH (Mot, Day, Yr.) August 10, 1955 ❑ Nursing Home /LTC ❑ Hospice Facility ® Decedent's Home ❑ Other (Specify) 9f. ZIP CODE 68801 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Kathy Ann Thurston 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mary Gertrude Hiser 14a. INFORMANT - NAME Kathy Ann Bohnart 16b. LICENSE NO. CITY / TOWN Gibbon 17a, FUNERAL NOME NAME AND MA LING ADDRESS (Street, City or Town, State) Au Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska CAUSE OF DEATH (See instructions and examples) T8. 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 cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: a) Metastatic Lymphoma, End Stage Non Hodgkins B Cell Lymphoma 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21a. MANNER OF DEATH ® Natural ❑ Homicide 0 Accident 0 Pending Investigation ❑ Suicide O Could not be determined 21b, IF TRANSPORTATION INJURY 0 tiriver /Operator 0 Passenger ❑ Pedestrian 0 Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION SEEN CONSIDERED? ❑ YES 0g] 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr.) December 5, 2017 STATE Nebraska 17t1.2ip Code 68801 APPROXIMATE INTERVAL 6 Months onset lode onset to death once 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES _.. ®NO 21c. WAS AN AUTOPSY PERFORMED ?: ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 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 Title) 26b, WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (MO:,?Day, Yr.) December 4, 2017 STANLEY S. OPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH