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ATaTr Ar •.t•n * Aa/ a `*6St� £SSt tY U 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 4/18/2018 LINCOLN, NEBRASKA 28b. DATE 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Richard Virgil Mendyk 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Loup City, Nebraska 7. SOCIAL SECURITY NUMBER 506 -40 -1145 8b. FACILITY -NAME (If not Institution, give street and number) 3004 W 15th Street 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9d, STREET AND NUMBER 3004 W 15th Street 9b. COUNTY Hall 10a. MARITAL STATUS AT TIME OF DEATH I)SJ Married L ❑:Married, trot separated ❑ Widowed ❑ Divorced 11. FATHER'S-NAME (First, Middle, Last, Suffix) Stanley Mendvk 13. EVER IN U.S, ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unit.) NO 15. METHOD OP DISPOSITION Burial ❑ Donation ❑ Cremation ❑ Entombment ❑'ReMoval ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Laurie D. Sheffield Westlawn Cemetery 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska IMMEDIATE CAUSE (Final disease or condition resulting in death) ., .., QUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) any, leading to The cause listed' on line a. Enter the UNDERLYING CAUSE tdisease or rnjurytriat indlated the events resulting in death) LAST • 20 :FEMALEt NOt pregnath Within past year ❑ Pregnant at time of death ❑ trot pregnart; but pregnant within 42 days of death ❑ Not preanam, Cut pregnant 43 days to 1 year before death .Unknown irpegnaat within the past year E 22a. DATE OF INJURY (Mo., Day, Yr.) 0 22d (NJURYATWORK? ❑Y ES ❑N 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 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 3a. DATE OF DEATH (Mo., Day, Yr.( Atrir 10.2018 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Never Married n Unknown a u Z u a O 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) GafySettie, MD 2 s 5a, AGE - Last Birthday (Yrs.) 83 14a. INFORMANT -NAME Annette Marie Mendvk 16d, CEMETERY, CREMATORY OR OTHER LOCATION 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could; not be determined CITY/TOWN 23b. DATE SIGNED (Mo., Day, Yr.) April 13, 2018 23c. TIME OF DEATH 09:43 PM 25, 01D TOBACOO USE OLI NTRIBUTE TO THE DEATH? ❑ YES NO ❑ PROBABLY ❑ UNKNOWN 5b. 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Gary Settle, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S {MATURE NDER 1 YEAR OS. DAYS 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient DOA c. CITY OR TOWN Grand Island 9e. APT. NO, 1013. NAME OF SPOUSE (First,, Middle, Last, Suffix) If wife, give maiden name Annette Marie Levi/andowski CAUSE OF DEATHjSee instructions and examples) 1a. PARf 1. 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) Myelodysplastic Syndrome 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Congestive Heart Failure STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 2. SEX Male 5c. UNDER 1 DAY HOURS 8d. COUNTY OF DEATH Hall I " 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Frances Stenka 18b. LICENSE NO. 1397 CITY / TOWN Grand Island 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger 0 Pedestrian 0 Other(Specify) 24a_ DATE SIGNED (Mo., Day, Yr.) 24c, PRONOUNCED DEAD (Mo., Day, Yr. 26a. HAS ORGAN OR TISSUE DONATION BE> N CONSIDERED? ❑ YES 1, NO MINS. 9f. ZIP CODE 68803 3. DATE OTHER ❑ Nursing Home /LTC ® Decedent's Home ❑ Other (Specify) April 10, 2018 6. DATE OF BIRTH (M May 27, 1934 ; 24b. TIME OF DEATH FILED BY REGISTRAR April 16, 2018 OF DEATH (Mo., Day, Yr.) Day onset onset to death onset:A ❑ Hospice Facility 16c. DATE (Mo„ Day, Yr.' April 14, 2018 9g. INSIDE CITY LIMITS El YES ❑ NO 14b. RELATIONSHIP TO DECEDENT,; SoOUSe 17b, Zip Code 68801 STATE Nebraska APPROXIMATE INT ERV AL onset to death 3 Years V w i 24e. On the basis of examination and /or investigation, In my opinion death occurred a p the time, date and place and due to the cause(s) stated. (Signature and Title) u U 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED?" ❑ YES I(J NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE 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 24d. TIME PRONOUNCED DEAD 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO