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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND `HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL 'RECORDS.':
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />1 DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES
<br />DATE OF ISSUANCE
<br />APR 15 2011
<br />LINCOLN, NEBRASKA
<br />201807845
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />CERTIFICATE OF DEATH 11
<br />HHS -61 11/03 (55061)
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Elmer W. Penas
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 7,,. 2011.-_,,-
<br />i
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ord, Nebraska
<br />5a. AGE -Last Birthday
<br />(Yrs.) 87
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo.. Day, Yr.)
<br />June 11, 1923
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS
<br />yiEF#�'
<br />v8b.
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<br />7. SOCIAL SECURITY NUMBER
<br />507-32-9166
<br />8a. PLACE OF DEATH
<br />HOSPITAL: 0 Inpatient OTHER: b1 Nursing Home/LTC ❑Hospice Facility
<br />0 ER/Outpatient ❑Decedent's Home
<br />0 oak ❑ Other (Specify)
<br />FACILITY -NAME (If not institution, give street and number)
<br />Golden LivingCenter Lakeview
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1405 W. Highway 34
<br />9e. APT. NO
<br />9f. ZIP CODE
<br />68801
<br />19g. INSIDE CITY LIMITS
<br />XI YES 0 NO
<br />__ n{
<br />10a. MARITAL STATUS AT TIME OF DEATH Si Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Marian Skala
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Lou Penas
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Bessie Morschek
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes.
<br />(Yes, no, orunk.) No
<br />14a. INFORMANT -NAME
<br />Marian Penas
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />;..
<br />�}.
<br />15. METHOD OF DISPOSITION
<br />❑Burial ❑Donation
<br />X1 Cremation ❑Entombment
<br />0 Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />None - Direct Cremation
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr. )
<br />April 7, 2011
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />Central Nebraska Cremation Service Gibbon, Nebraska
<br />- =>'
<br />7a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel 3005 South Locust Street Grand Island NE
<br />17b. Zip Code
<br />68801
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<br />18. 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, APPROXIMATE INTERVAL
<br />18.
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. 1
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Final (a) / " ^` 1/) v G A lG E p Y
<br />disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />In death)
<br />Sequentially list conditions, If (b)
<br />any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />on a.
<br />Enter ertha UNDERLYING CAUSE
<br />(disease or Injury that Initiated (c)
<br />the events retuning in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST
<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.
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<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES NO
<br />20.16 FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />y4Natural 0 Homicide
<br />0 Accident❑ Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES 10
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />0 Suicide 0 Could not be determined
<br />0 Pedestrian
<br />❑Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />❑ YES 0 N
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 122b. TIME OF INJURY
<br />•
<br />22c. PLACE OF INJURY -At home. farm,
<br />street, factory, office building, construction
<br />site, etc. (Specify)
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<br />22d. INJURY AT WORK?
<br />❑ YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
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<br />221. LOCATION OF INJURY - STREET 8, NUMBER, APT. NO. CRY/TOWN STATE ZIP CODE
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<br />23a. DATE OF DEATH (Mo., Day, Yr.)z
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<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b.TIME OF DEATH
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<br />23b. DATE SIGNED o., Day, Yr. 23c. TIME OF DEATH
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<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
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<br />23d. To the best of my knowledge, death occur ed al the time, date and place
<br />and due to the c (s) stated. 'gnature d tie) ♦
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<br />0 _ z 0
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<br />246. 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 )
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<br />25. DID TOBACCO USE NTRIBUTE TO THE DEATH?
<br />YES ❑ NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES 540
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES ;it NO
<br />NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />t/14 /- - Cd uwv "A 7a- S Nv 4.4.ria iI lidI L*t44 ,/£ Ggid Y
<br />28a. REGISTRAR'S SIGNATURE
<br />1161 A
<br />.
<br />I 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />APR 1 3 2094
<br />HHS -61 11/03 (55061)
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