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STATE OF NEBRASKA
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />1 6 • 28€32 S 110. Rd
<br />WHEN THIS ? COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />201804351 STANLEY S. DOPER
<br />DATE OF ISSUANCE
<br />8/10/2017
<br />LINCOLN, NESRASKA
<br />7. SOCIAL SECURITY NUMBER
<br />a 505-35-9010
<br />IMMEDIATE CAUSE:
<br />eare ....,
<br />disease or Lurid'.' +uh ,asaltiitg
<br />fn death)
<br />Sequentially list Cnndfh
<br />any, tejidine to the cause listed:
<br />Enter the UNDERLYING CAUSE
<br />idisease orrn)ury:that initiated
<br />DUE TO, OR AS n CONSEQUENCE OF:
<br />b) Congestive Heart Failure
<br />DUE TO, OR AS A CONSEQUENCE OF
<br />c)
<br />DATE OF D ATH (Mo., Day, Yr.)
<br />3b. DATE SIGNED "(Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />8a. PLACE OF DEATH
<br />riSSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH': AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Pete Fotinos
<br />4. C ITY AND STATE O
<br />Scottsbluff, !Nebraska
<br />R TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />89
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />July 19, 2017
<br />July 15, 1928
<br />6. DATE OF BIRTH (Mo., Day
<br />Yri)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES J NO
<br />OTHEk i I Nursing Home /LTC
<br />® Decedents Home
<br />❑ Other (Specify)
<br />i ct i 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />• Wood River 68883
<br />d 9 a, RESIDENCE -STATE
<br />W Nebraska
<br />LL ' 9d. STREET AND NUMBER
<br />n 2802S110Rd
<br />a 1
<br />9b. COUNTY
<br />Hall
<br />3a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />D. Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />0.
<br />i3. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, Or upk.l Yes '12/10/1952- 12/09/1954
<br />1
<br />15. METHOD OF DISPOSITION
<br />Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />❑:Removal •❑ Other (Specify)
<br />16a. EMBALMER - SIGNATURE
<br />Matthew T. Myers
<br />CAUSE OF DEATH -e in ruc i.ns and exam•Ies
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Wood River
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name:
<br />Joyce Becker
<br />-- 11. FATHER'S-NAME (First,
<br />• George Fotinos
<br />Middle, Last, Suffix)
<br />I ' 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Katherine Johns
<br />14a. INFORMANT -NAME
<br />Joyce Fotinos
<br />16b. LICENSE NO.
<br />1411
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Livingston- Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />9g.!NSIDE CITY LIMITS
<br />❑ YES 10 NO
<br />14b. RELATIONSHIP. TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />July 22, 2017
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />CITY / TOWN
<br />Grand Island
<br />STATE
<br />tebraska
<br />1 7b Zip Code
<br />68803 •
<br />'It PART'. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. 00 NOT enter terminal events such as cardiac arrest,
<br />reSpiratdty aneSt. or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. E1det only one cause An line. Add additional lines if necessary.
<br />APPROXIMATE`INTE
<br />onset to death
<br />Minutes
<br />onsettOdeath
<br />7 -8 Years
<br />onset to death
<br />::;he events resiln
<br />LAS
<br />•
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Deceased On Oxygen 24 Hours A Day
<br />20.IFFEMALE:
<br />Not pregnantwlthin past year
<br />0 Pregnant at time of death
<br />© Not pregnant, Sot preynant within 42 days of death
<br />Nvt pregnant,i501 pregnant:4S days to 1 year before death
<br />❑ Upkndwrt if pregnaot witltfil the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. AT :%NORIC?
<br />❑YES ❑NO
<br />22b. TIME OF INJURY
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />❑ Suicide Could not be determined
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ NO
<br />21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />❑ Oriver /Operator
<br />❑ YES ® NO
<br />❑ Passenger
<br />0 Pedestrian
<br />Other:(Specrfy)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CABS E CIF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />CITY /TOWN
<br />STATE
<br />24a. DATE.. SIGNED (Mo., Day, Yr.) - 24b. TIME OF DEATH
<br />uiy "c1 2017 Aooro;:. 05 I- Alvi
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED .DEAD
<br />:r
<br />July 19, 2017 06:05 AM
<br />24e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />Gait VerMaas, Hall Deputy County Attorney
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑., NO
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ❑ NO ❑ PROBABLY I UNKNOWN
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Gail VerMaas, Hall Deputy County Attorney, 231 S Locust P.O. Box 367, Grand Island, Nebraska, 68802
<br />8a, REGISTRAR'S SIGNATURE - Co- 28b. DATE FILED BY REGISTRAR (Mo„ Day Yr.)
<br />August 3, 2017
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