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STATE OF NEBRASKA WHEN € THIS r° 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 5/25/2018 LINCOLN, NEBRASKA 201807141 STANLEY . COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 18 06612 To be completedlverified by: FUNERAL DIRECTOR 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Pauline NMN Mazankowski 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) May 15, 2018 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Wood River, Nebraska (Yrs.) 95 MOS. DAYS HOURS MINS. January 15, 1923 7. SOCIAL SECURITY NUMBER 507-24-5996 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) 8080 South 90th Road ❑ ER/Outpatient 0 Decedent's Home 0 DOA ® Other (specify)Grandson's Home 8c. CITY OR TOWN OF DEATH (Include Zip Code) Wood River 68883 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE COUNTY Nebraska 19b. Hall 9c. CITY OR TOWN Wood River 9d. STREET AND NUMBER 1401 East St. 9e. APT. NO. 9f. ZIP CODE 68883 9g. INSIDE CITY LIMITS ® YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH 0 Married ❑ Never Married Married, but separated 0 Widowed ® Divorced 0 Unknown 10b. NAME. OF SPOUSE (First,.. Middle, Last, Suffix) If wife, give maiden name 11. FATHER'S.NAM£ (First, Middle, Last, Suffix) Arthur Wiese 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Dora Bockmann 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. {Yes, No, or unk.) No 14a. INFORMANT -NAME Dennis Huxtable 14b. RELATIONSHIP TO DECEDENT Son 15. METHOD OF DISPOSITION ®'burial ❑Donation 16a. EMBALMER -SIGNATURE Gwen K. Hyronemus 16b. LICENSE NO. 1448 16c. DATE (Mo., Day, Yr.) May 22, 2018 o Cremation ❑Entombment o Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Wood River Cemetery Wood River Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) ADfel Funeral Home, 1123 W. 2nd. Grand Island. Nebraska IIII 17b. Zip Code I 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 18. PART I. Enter the chain of events --diseases, injuries, or complications -that directly caused the. death. DO NOT enter tennmal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines 1 necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) End Stage Vascular Dementia disease or condition resulting onset to death 10 Years in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if <: b)Chronic Cerebrovascular Disease any, leading to the cause listed on line a. onset to death 20 Years DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Idiseaae or injury: that initiated onset to death the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE: '= 0 Not pregnant witldn past year 0 Pregnant at time of death 21a. MANNER OF DEATH : ® Natural 0 Homicide 0 Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO o Not pregnant, but pregnant within 42 days of death,❑ ❑ Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year 0 SuicideCould not be determined 0 ermne : Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.)i22b. TIME OF INJURY 22c.IPLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? = ❑YES DNO 22e. DESCRIBIE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITU/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) May 15, 2018 To be completed by CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) May 15, 2018 23c. TIME OF DEATH 02:45 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Steven Husen, MD 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) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES 0 NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR ISSUE • s ATION BEEN CONSIDERED? 0 YES 0 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE ,06- 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) May 23, 2018