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STATE OF NEBRASKA n . t ,,, ,1kxt fa DXX 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 1/4/2017 LINCOLN, NEBRASKA 201803782 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. a OPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Dennis Paul Franzen 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Gothe • tburfj Nebraska 7. SOCIAL SECURITY NUMBER 508 -64 -1713 O 8b. FACILITY -NAME (Ifnot Institution, give street and number) Veterans Affairs Medical Center rt 8c. CITY OR TOWN OF DEATH (Include Zip Code) Q Grand Island 68803 9a. RESIDENCE -STATE • Nebraska .. LL 9d. STREET AND NUMBER • 2201 N. Broadwell Ave a 10a. MARITAL STATUS-AT TIME OF DEATH ® Married ❑ Never Married E ❑ Married, brit separated; ❑ Widowed ❑ Divorced ❑ Unknown CD 11. FATHER'S -NAME (Firs *., Middle, Last, Suffix) Paul Henry Franzen £ 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. 8 (Yes, Na, or Unk.) Yes 11/14/1967-08/22/1969 15. METHODOF - F ® Burial '' Donation ❑ Cremation ❑ Entombment • ❑ Removal Qatar (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Nelson -Bauer Funeral Home. 401 Burlinaton St. Holdreae. Nebraska CAUSE OF DEATH (See instructions and examples) 13. PART 1. Enter the chain of events- injuries, or complications -that directly caused the death. DO NOT enter tenninal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one causes on a line Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Aspiration Pneumonia Sequentiaity list ennditiogs, if any, reeding to the:cause listed (' on line W. Enter the. UNDERLYING CAUSE Adisesee or Injury that initiated the avers resuitin9 in death) DUE TO, OR AS A CONSEQUENCE OF: LAST „.. d) . 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Seizure Disorder, Diabetes Mellitus Type 2 20. IFFEMALE: ❑ Not pregnant :within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Tlot pregnant, bu1,pregrtant 43 days to 1 year before death ❑ i2nknown if pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d,:(NJURY AT WORK? ❑YES ❑NO._... 22f. LOCATION OF INJURY STREET 8, NUMBER, APT.NO. 3d. To the best of my knowledge, death occurred at the time, date and place and due to the causes) stated. (Signature and Title) Shawn S, Lawrence, MD E y e; U ti V z < O z E 27. NAM 5a. AGE - Last Birthday (Yrs.) 69 9b. COUNTY Hall 16a. EMBALMER- SIGNATURE Tracey Dietz 16d. CEMETERY, CREMATORY OR OTHER LOCATION Hope Lutheran Cemetery DUE TO, OR AS A CONSEQUENCE OF: b)Traumatic Brain Injury DUE TO, OR AS A CONSEQUENCE CF: c)Accidental Fall 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 23a.. DATE OF DEATH (Mo., Day, Yr.) December 24, 2016 23b. DATE SIGNED (Mo., Day, Yr.) December 28, 2016 23c. TIME OF DEATH 01:48 AM 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? YES ❑ NO ❑ PROBABLY ® UNKNOWN 28a, REGISTRAR`S SIGNATURE 1 6 I 1 ° 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ ERiOutpatient ❑ DOA 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Carol Peterson 12. MOTHER'S.NAME (First, Middle, Maiden Surname) Ruth Anna Marie Fastenau 14a. INFORMANT -NAME Lori Kuck 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide 0 Could not be determined 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) CITY/TOWN 5b. UNDER 1 YEAR MOS. 9c. CITY OR TOWN Grand Island DAYS HOURS 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY CITY / TOWN Smithfield STATE MINS. 8d. COUNTY OF DEATH Hal; 16b. LICENSE NO. 1328 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES El NO E, TITLE AND ADDRESS OF CERTIFIER (Type or Print Shawn S Lawrence, MD, 223 South E St, Broken Bow, Nebraska, 68822 ❑ Nursing Home/LTC ❑ Decedent's Home ❑ Other (Specify) 9f. ZIP CODE 68803 3. DATE OF DEATH (Mo., Day, Yr.) December 24, 2016 6. DATE OF BIRTH (Mo., Day, Yr.) April 12, 1947 14b. RELATIONSHIP TO DECEDENT Sister 16c. DATE (Mo., Day, Yr) December 28, 2016 STATE Nebraska 17b, Zip Code 68949 APPROXfMATEINTERVAL onset to death 2 months onset to? death:' Years onset to death Years onset to death` 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 10 NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSEOF DEATH ? , ❑ YES ❑ NO 24b. TIME OF DEATH ❑ Hospice Facility 9g. INSIDE CITY LIMITS ® YES ❑ NO 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) 28b. DATE FILED BY REGISTRAR (NI O» ba : December 29, 2016 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO