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Pursuant to section 30 -2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Dennis Leo Mason 2. SEX Male 3, DATE OF DEATH (Mo., Day, Yr.) Found August 20, 2018 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 54 513 UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) January 12, 1964 MOS. - DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -96 -4422 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) 3618 Bronco Road ❑ ER/Outpatient El Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCESTATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 3618 Bronco Road 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ❑ 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 Corrina Matlock 11. FATHER'S -NAME (First, Middle, Last, Suffix) : Lonnie Mason 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Kathleen Cronin 13. EVER IN U,S,ARhMED FORCES? Give dotes c`, sc: rcn if Yes. (Ycs, No, or Unk.) Yes 11/16/1982- 08/26/1985 { 14a. INFORMANT -NAME I Corrine Mason 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION 10 Burial 0 Donation ❑ Cremation 0 Entombment 0 Removal ❑ other (Specify) 16a. EMBALMER- SIGNATURE Chris McCoy 16b. LICENSE NO. 1191 16c. DATE (Mo., Day, Yr.) August 27, 2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Burkett Cemetery Grand Island Nebraska 17a, FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) ADfel 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 death. DO NOT enter tenninal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death Immediate respiratory arrestor ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a tine. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Coronary Occlusion disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onse t0 death Seguentlally tin cundltions if b) any, leading to the cause fisted on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (disease or injury that initiated the events restating in death) < DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) B. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Alcoholism 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? El YES : ❑ NO 2, IF FEMALE: !' ❑ Notpregnant 'withinpastyear 0 Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 41 days to 1 year before death ❑ Unknown 4 pregnant within the past year 21a. MANNER OF DEATH Ea Natural Er Homicide ❑ Accident ❑ Pe Cation 0 Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY ❑Driver /Operator Passenger ❑ ❑ Pedestrian ❑ Other (Specify) PERFORMED'? 21c. WAS AN AUTOPSY PERFORMED ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE L-t --��t CAUSE OF DEATH? ❑ YES NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ' ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) August 21, 2018 24b. TIME OF DEATH Unknown 23b. PATE SIGNED (Mo., Day, Yr.) mpleted CERTIF NLY t7 C]: fc} 3 0 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) August 20, 2018 24d. TIME PRONOUNCED DEAD 05:45 PM 12 3d. To the best of my knowledge, death occurred at the time, date and place and due to the causeis) 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 causeis) stated. (Signature and Title) Matthew C. Boyle, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES ❑ NO ❑ PROBABLY El 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 Matthew G. Boyle, Hall Deputy County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801 28a. REGISTRAR'S SIGNATURE � I �" , d'� . 28b. DATE FILED BY REGISTRAR (Mo:, Day, Yr.) August 28, 2018 DATE OF ISSUANCE 9/5/2018 LINCOLN, NEBRASKA WHEN ! THIS COPY CARRIES THE RAISER 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 RUSSELL FOSLER DEPARTMENT HEALTH AND INTERIM ASSISTANT STATE REGISTRAR HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH <r7, Tryl11111"/t a•