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,ta4,'t?rr3aitiviiE.,s:34>) • 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 /S THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 12/17/2018 LINCOLN, NEBRASKA 201901118RUSSELL O SLER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 18 15650 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 whe a the decedent residedat the time of death. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) A E Van Wie AKA August Eugene Van Wie 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) December 1, 2018 4. CITY ANO 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.) Indianola, Iowa (Yrs.) 83 MOS. DAYS HOURS MINS. November21, 1935 7. SOCIAL SECURITY NUMBER 507-36-3513 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER ® Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Good Samaritan Society -Grand Island Village 0 ER/Outpatient 0 Decedent's Home 0 DOA 0 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 Grand Island 9d. STREET AND NUMBER 10 Kuester Lake 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS 0 YES ® NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married ❑ Married, but separated ` 0 Widowed 0 Divorced 0 Unknown 1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Connie Joy Underberq 11. FATHER'S -NAME (First, Middle, Last, Suffix) 112. MOTHER'S -NAME (First, Middle, Maiden Surname) Peter A Van Wie 1 Karna Juline 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 11/02/1961-04/12/1962 14a. INFORMANT -NAME Connie Joy Van Wie 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial 0 Donation 16a. EMBALMER -SIGNATURE Katie M. Smvdra 16b. LICENSE NO. 1454 16c. DATE (Mo., Day, Yr.) December 7, 2018 ❑ Cremation 0 Entombment ❑.Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska 17b, Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART I. Eller thechain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal 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 if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting onset to death Immediate in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b)Congestive Heart Failure any, leading to the. cause Iwted. linea. onset to death Years on DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Chronic Kidney Disease (disease or injury that initiated onset to death Years the events resultmgi0 death) DUE TO, OR AS A CONSEQUENCE OF: wsT d) Diabetes onset to death Years 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Dementia. Patient Transitioned To Hospice And Died 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE: ❑ Not pregnant within past year Pregnant at time of death ❑El 21a. MANNER OF DEATH ® Natural 0 Homicide Accident ElPendingInvestigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? 0 YES ® NO 0 Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year 0 Suicide 0 Could not be determined 0 Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES ❑ NO 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) 22!NjU V AT WORK? 'aff. sc.....v_c nw. i,'(j n! 1..... .na, ❑YES ©NO 22f. LOCATION OF INJURY - STREET 8. NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) December 1 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.) December 3, 2018 23c. TIME OF DEATH 09:15 PM 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) Michael A. Donner, 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 Tide) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES ® NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR ISSUE • e ATION BEEN CONSIDERED? 0 YES 7 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 Michael A. Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 10, 2018