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" y Mni . /I i.. ). k.,1..1 .1 STATE OF NEBRASKA eV ii' ° °i'' Wi n_ E 0 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 11/13/2017 LINCOLN, NEBRASKA 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) John Joseph Melnick Sr 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Erie, Pennsylvania 7. SOCIAL SECURITY NUMBER 208.14 -6453 8b. FACILITY -NAME (Knot Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand :Island, 68803 95. RESIDENCE -STAT Nebraska 9d. STREET AND NUMBER 225 South Buffalo Road Ra MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married 0 Married, butseparate4 ❑ Widowed ❑ Divorced ❑ Unknown 1. FATHER'S -NAME (First; Middle. Last Suffix) Stephen Melnick EVERIN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME (Yes, No, or Unk.) Yes ; 01/30/1946-12/31/1946 Sarah Melnick 5. METHOD OF AiSPOSIT*ON 16a. EMBALMER - SIGNATURE E Burial 0 Donation E Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) ADfel Funeral Horne. 1123 W. 2nd, Grand Island. Nebraska IMMEDIATE CAUSE (Final disease or condition resulting in death) Sequentially ran conditions, if any, teadinglo the cause listed on line a. Enter the UNDERLYING CAUSE toYtseae er injuN tlYat mitiat0ti the ;wen ts resuning death) LAST i rL's 17, 20. IF FEMALE: ❑ Not pregnant within past year U ❑ Pregnant at time of death iA ❑ Not Pregnant,,. but pregnant within 42 days of death ❑ Not pregnant, but preonant days to 1 year before death ❑Unknown if pregnant X+rthirithe past year 22a. DATE OF INJURY (Mo., Day, Yr.) STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 9b. COUNTY Hall Gwen K. Hvronemus d. INJURY AT IVORK? 22e. DESCRIBE HOW INJURY OCCURRED OYES 0 N 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon PART1. Enter the sham' Of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest,or ventricplar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause On a line. Add additional lines if necessary. IMMEDIATE CAUSE: a)Congestive Heart Failure DUE TO OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Chronic Obstructive Pulmonary Disease 23a. DATE OP DEATH (Mo., Day, Yr.) October 27, 2017 23 b. DATE SIGNED ` (Mo ., Day, Yr.) 23c. TIME OF DEATH October 27, 2017 06:52 AM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the causes) stated. (Signature and Title) Donald Wirth, MD 21a. MANNER OF DEATH E 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 Donald Wirth, MD, 2116 W Faidley #400, Box 9802, Grand Island a. 'REGISTRA R'I`s S10NATURE 201803889 5a. AGE - Last Birthday (Yrs.) 91 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/Outpatient ❑ DOA 5b. UNDER 1 YEAR MOS. 9c. CITY OR TOWN Doniphan DAYS 1x. MOTHER'S -NAME !First. Catherine Sparoon STANLEY S. OOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 9e. APT. NO. 19f. ZIP CODE 68832 l Ob. NAME OF SPOUSE (First, Middle, Last, Sarah Youngblood 16b. LICENSE NO. 1448 CAUSE OF DEATH (See instructions, and examples) Middle. 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other(Speciify) ate 3. DATE OF DEATH (Mo., Day, Yr.) October 27, 2017 6. DATE OF BIRTH (Mo., Day, Yr. November 1, 1925 Suffix) If wife, give maiden name Maiden Surname) ❑ Hospice Facility 1 9g. INSIDE CITY LIMITS ❑ YES E NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) November 1, 2017 STATE Nebraska 1713. Zip Code 68801 APPROXIMATE INTERVAL onset to death 1 Year onset to death onset to death onset t0 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED? '> ❑ YES E NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OP DEATH? ❑ YES ❑ NO 22b. TIME OF INJURY 122c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) J (�1 - j CITY /TOWN Nebraska, 68803 STATE 24a. DATE SIGNED (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES ENO 24b. TIME OF DEATH 240. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED D 28b. DATE FILED BY REGISTRA November 6, 2017 ZIP CODE 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 Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO DYES ❑ NO (Mo„ Day, Yr.)