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Pursuant to section 30 -2413, demands for notice which may affect the estate of the deceased arm filed with the county court in the county where the decedent resided at the time of death. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Paul Earl Vierk 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) August 9, 2018 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 66 5b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) November 21, 1951 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -60 -0301 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility 8b. FACILITY -NAME (ff not Institution, give street and number) CHI Health St. Francis ® ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other(Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Cairo 9d. STREET AND NUMBER 208 West Egypt 9e. APT. NO. 9f. ZIP CODE 68824 9g. INSIDE CITY LIMITS IE YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b.. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Jana Young 11. FATHER'S -NAME (First, Middle, Last, Suffix) Glen Vierk 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Winifred Donigan 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or link.) No 14a. INFORMANT -NAME Jana Vierk 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ 0 Donation ® Cremation 0 Entombment ❑Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) August 10, 2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL. HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Aofel Funeral Home, 1123 W. 2nd. Grand Island. Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART 1. Enter the chain of events- - diseases, injuries, or complications -that directly caused the deattf. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death Hour respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines 4 necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a)Unknown Natural Causes =ease or condition resulting m death) onset to death DUE TO, OR AS A CONSEQUENCE OF: sequentially list conditions, if b) Systolic Heart Failure any, leading to the cause listed line on a. onset to death DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease er injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death t not resulting in the underlying cause given in PART I. lschemic Dilated Cardiomyopathy, Chronic Kidney Disease 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®'NO Q. IF FEMALE: ❑ Not pregnant within past year an eat ❑ regn 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 21a. MANNER OF DEATH ® Natural 0 Homicide ❑ Accident ❑ Pending Investigation ❑ suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ®NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NQ 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? OYES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE Z3... ;DA OF OE,:Ti-: (ono., Day, Vi.) To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY :4a. DATE c :ct4 °_ , Day, Yr.) August 9, 2018 24b. TIME 07 ,.Zit. 12:51 AM 23b. DATE SIGNED (Mo., Day, Yr.) mpleted CERTIFI NLY w' a q II m 0 0 0 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) August 9, 2018 24d. TIME PRONOUNCED DEAD 12:51 AM 12 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) 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) Sarah Hinrichs, Hall Deputy County Attorney `- 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Sarah Hinrichs, Hall Deputy County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801 _ 28a. REGISTRAR'S SIGNATURE 1C---------- J °`� , 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) August 14, 2018 yynxeq 6i ° FV,.... 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 8/17/2018 LINCOLN, NEBRASKA RUSSELL FOSLER DEPARTMENT HEALTH AND INTERIM ASSISTANT STATE REGISTRAR HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH