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'w d u 1 viAlku.%.% i'k'v',E1.4 k 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 12/18/2017 INCOLI4 NEBI5 SKA 201803866 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Daniel Ernest Ohlman 4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Kearney, Nebraska 7. SOCIAL SECURITY NUMBER . FACILITY -NAME (tf not give street and number) Veterans Affairs Medical Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska Enter the UNDERLYING. CAUSE c) 1liseaae et3njjury:that intitaed:�. the srema resuit+x±9 in deaths E 22a. DATE OF INJURY (Mo., Day, Yr.) a 22d. INJURY AT WORK? • 1- 0 ❑ YES ❑ NO • 23a. DATE OF DEATH (Mo., Day, Yr.) December 3 2017 I b. DATE SIGNED (Mo., Day, Yr.) December 4, 2017 9b. COUNTY Hall 9d. STREET AND NUMBER 7862 West Guenther Road Oa. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑'Married, but separated' ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (Rust, Middle, Last, Suffix) Ernest Ohlman 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 09/19/1970-02/20/1972 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment O Removal ❑ Other (Specify) 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Arfel Funeral Horne, 1123 W. 2nd. Grand Island, Nebraska DUE TO, OR AS A CONSEQUENCE OF: LL 20. IF FEMALE- ' m ❑ Not pregnant Within past year V ❑ Pregnant at time of death Not pregnant, but pregnant within 42 days of death .ti ❑ Not pregnant,: but pfagnam 43 days to 1 year before death ❑ tlnknOwn if pregnant wittdn the past year 22b. TIME OF INJURY 3d. To the best of my knowledge, death occurred at the time, date and place and due to the causels) stated. )Signature and Title) Shawn S. Lawrence, MD 23c. TIME OF DEATH 12:27 PM 28a. REGiSTRAf!'S SIGNATURE 06- aftromet- AGE - Last Birthday (Yrs.) 21a. MANNER OF DEATH 0 Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ could not be determined 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Shawn S. ,Lawrence, MD, 223 South E St, Broken Bow, Nebraska, 5b. UNDER 1 YEAR MOS. 16a. EMBALMER-SIGNATURE Chris McCoy DAYS 9e. APT. NO. 26a. HAS ORGAN OR TISsUE Ti s e ATION BEEN'CONSIDERED? ❑ YES i1 NO 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH HOSPITAL © Inpatient ER/Outpatient ❑ DOA OTHER ❑ Nursing Home/LTC ❑ Decedent's Home ❑ Other (Specify) Hospice Facility 8d. COUNTY OF DEATH Hall CAUSE OF DEATH (See instructions qnd examples) 18. PART I. Enter tilt chain of events- .diseases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratdty arrest, or ventli ular 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) Progressive Supranuclear Palsy disease or condition resulting in death) xt Sequentiallyhsl c onditions, if 4 -; b) any, leading to the _ cause listen on lute e. - DUE TO, OR AS A CONSEQUENCE OF: 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 9f. ZIP CODE 68810 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Alvera Stelk 14a. INFORMANT- NAME Teresa K;Ohlman 16b. LICENSE NO. 1191 18. PART II.OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. HTN,Bladder Outlet Obstruction, Obstructive Sleep Apnea 3. DATE OF DEATH (Mo., Day, Yr.) December 3, 2017 May 9, 1950 6. DATE OF BIRTH (Mo. Day, Yr.) 9g. INSIDE CITY LIMITS ❑ YES ® NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Teresa K Luth 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) ,. December 8, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE Nebraska Years 17b. Zip Code .. 68801 A PP RO7(IMATE (NTERVAL onset to death LAST.: DUE TO, OR AS A CONSEQUENCE OF: d) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? ❑ DdverlOperator ❑ Passenger ❑ YES ® NO ❑ Pedestrian Q Other(Specify) 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) 22e. DESCRIBE HOW INJURY OCCURRED 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 causes) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mos December 13, 2017 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Car STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES