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aren WREN 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 3/24/2017 LINCOLN, NEBRASKA 44GiVNX�Y Mt 201804213 STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Coe 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Edward Emil Hannon 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Omaha, Nebraska 7. SOCIAL SECURITY NUMBER 212 -34 -2625 8b. FACILITY -NAME (If not Institution, give street and number) w High Plains Alzheimer's Special Care Center D_ 8c. CITY OR TOWN OF DEATH (Include Zip Code) B Lincoln 68516 8d. COUNTY OF DEATH I l Lancaster 9b. COUNTY Lancaster 9a RESIDENCE -STATE Nebraska n 9d. STREET AND NUMBER u. • 3211 South 76th Street A toe. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ar 0. Married, bat separated; ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First; Middle, Last, Suffix) :: Daniel B Hannon 2. MOTHER'S -NAME (First, Middle, Maiden Surname) Elizabeth Moore E 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yee, No, or Unk.) Yes ('07/23/1950- 07/20/1955 • 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment Removal ❑ Other, (Specify) 16a. EMBALMER- SIGNATURE Steve Olson 16d. CEMETERY, CREMATORY OR OTHER LOCATION Calvary Cemetery Lincoln 17a. FUNERAL NOME NAME AND MA LING ADDRESS (Street, City or Town, State) Roper & Sons. Inc.. 4300 0 Street. Lincoln. Nebraska t 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 tine,, Add additional lines if necessary. IMMEDIATE CAUSE. a) Congestive Heart Failure IMMEDIATE CAUSE (Final disease or condition resulting in death) Segtieinially list ftufitidns, if >: any leading to the F.080 listed on line a. 22a. DATE OF INJURY (Mo., Day, Yr.) 23a. DATE OF DEATH (Mo., Day, Yr.) March 16, 2017 23b. DATE SIGNED (Mo., Day, Yr.) March 22, 2017 DUE TO, OR AS A CONSEQUENCE OF: b)Atherosclerotic Cardiovascular Disease DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) . (diseasaor injury that initiated the events resulting in death) LAST ... 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 1. Pneumonia 20. IF FEMALE: ;I ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not Pregnant but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 22b. TIME OF INJURY d. INJURY ATWORK? ;❑ YES ❑ NO 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 23c. TIME OF DEATH 05:00 PM 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) Daniel E inspahr, MD .... ........ ....... ...... 25. `DID TOBACCGUSE CONTRIBUTE. THE DEATH? ❑ YES I NO ❑ PROBABLY ❑ UNKNOWN Se. AGE - Last Birthday (Y.) 85 8a. REGISTRAR'S SIGNATURE 5b. UNDER 1 YEAR MOS 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient 0 DOA 14a. INFORMANT -NAME Mary Hannon CAUSE OF DEATH (See instructions and examples) 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation 0 Suicide 0 Could not be determined CITY/TOWN DAYS HOURS 9e. APT. NO. 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 0 NO 2. SEX Male 5c. UNDER 1 DAY CITY/TOWN MINS. 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ Pedestrian Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) OTHER ❑ Nursing Home/LTC ❑ Decedent's Home ® Other (Specify)ASSISTED LIVING 9f. ZIP CODE 68506 16b. LICENSE NO. 0912 STATE 3. DATE OF DEATH (Mo., Day, Yr.) March 16, 2017 6. DATE OF BIRTH (Mo., Day, TO September 3, 1931 ?. 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑.YES ❑ Hospice Facility 9c, CITY OR TOWN Lincoln 9g. INSIDE CITY LIMITS' ® YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Mary La Greca 14b. RELATIONSHIP TO DECEDENT Spouse . 16c. DATE (Mo., Day, Yr.) March 21, 2017 STATE Nebraska 17b.ZIp Code 68510 onset to death Years onset to death onset to death ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 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 causets) stated. (Signature and Tree) 28b. DATE FILED BY REGISTRAR (Mo„ Day, Yr.) March 23, 2017 APPROXIMATE I N TERVAI. onset to de8tIi Weeks 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ 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) 22e. DESCRIBE HOW INJURY OCCURRED ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Daniel Einspahr, MD, 3901 Pine Lake Road, Lincoln, Nebraska, 68516