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<br />it
<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 />DATE OF ISSUANCE
<br />12/26/2018
<br />LINCOLN, NEBRASKA
<br />RUSSELL FOSLER
<br />2 019 0 0 519 ASSISTANT REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />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.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />James Frederick Lentz
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November 14, 2018
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Yankton, South Dakota
<br />(Yrs.)
<br />71
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />December 31, 1946
<br />7. SOCIAL SECURITY NUMBER
<br />508-66-3503
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />211 East Canfield Street
<br />0 ER/Outpatient ® Decedent's Home
<br />❑ DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Vv y� .. =. 8_72-r
<br />I 8d. COUNTY OF DEATH
<br />I Cedar
<br />lea. RESIDENCE-$TATE95.
<br />Nebraska `
<br />COUNTY 9c. Cil i OR TOWN
<br />I Cedar I Coleridge
<br />9d. STREET AND NUMBER
<br />211 East Canfield Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68727
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARtTAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Glenna Joy Paro
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Irvin Ronald Lentz
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Cecelia Marie Burbach
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) yes 03/28/1966-03/10/1969
<br />14a. INFORMANT -NAME
<br />Glenna Joy Lentz
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Gerald A. Wintz
<br />16b. LICENSE NO.
<br />1041
<br />16c. DATE (Mo., Day, Yr.)
<br />November 20, 2018
<br />® Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Dakota Cremation Services Sioux Falls South Dakota
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Wintz Funeral Home. Inc.. 203 W. Franklin Street, PO Box 505. Hartington, Nebraska
<br />17b. Zip Code
<br />68739
<br />CAUSE OF DEATH (See instructions and examples)
<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,
<br />APPROXIMATE INTERVAL
<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.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Diffuse Large B-cell Lymphoma Of Chest
<br />disease or condition resulting
<br />onset to death
<br />Years
<br />in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading to thecause listed
<br />onset to death
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />IEnter the UNDERLYING CAUSE CI
<br />:tecase _ inmat °
<br />onset to death
<br />the events resulting m death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Diabetes Mellitus, Asthma
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ NO
<br />20. IF FEMALE:.
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />Accident Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<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 />❑ ❑
<br />0 suicide 0 Could not be determined
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d, INJURY AT WORK? ;
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />e
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 14, 2018
<br />To b., completed by,
<br />CORON 2R'S PHYSICIAN
<br />or COI INTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />li rc >
<br />I 0 z
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 21, 2018
<br />23c. TIME OF DEATH
<br />11:13 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />a 0
<br />a o
<br />:
<br />.23d. To the best of my knowledge, death occurred at the time, date and place
<br />000 nue to :ne cause(si state, iS:gnature and ❑tie)
<br />Tyler L. Hanson, MD
<br />24e. On the basis of examination andbr invest!pation. M my opinion death occurred a:
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY ® UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES 1 NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Tyler L. Hanson, MD, 1104 West 8th Street, Yankton,
<br />Nebraska, 57078
<br />28a. REGISTRAR'S SIGNATURE/'7
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 21, 2018
<br />�'�`�
<br />RECORDEDD -)n
<br />CLERK CI REG. OF DEEDS
<br />DAVID DOWLING
<br />CEDAR COUNTY, NE
<br />
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