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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 /S THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE ISk
<br />TANLEY . COOPE� R "
<br />201901514 ASSISTA STATE REGISTRAR
<br />4/13/2018 DEPARTMENT HEALTH AND
<br />LINCOLN, NEBRASKA HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />2. SEX
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />Peter James Bilotta
<br />Male
<br />March 29, 2018
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Sa. AGE -Lost Birthday
<br />b UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yrs.)
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />South Africa
<br />66
<br />October 9, 1951
<br />7. SOCIAL SECURITY NUMBER
<br />8a. PLACE OF DEATH
<br />261-17-3333
<br />HOSPITAL © Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility
<br />Sb. FACItITY-NAME (if not institution, give street and number)
<br />❑ £R/Outpatient ❑ Decedent's Home
<br />0
<br />Veterans Affairs Medical Center
<br />❑ DOA ❑ Other (Specify)
<br />ILI-8c.
<br />CITY OR TOWN OF DEATH (include Zip Code) i
<br />6d. COUNTY OF DEATH
<br />°
<br />Grand Island 68803
<br />Hall
<br />_J
<br />9
<br />9a. RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY OR TOWN
<br />w
<br />z
<br />Nebraska !
<br />Hall
<br />Grand Island
<br />R
<br />9d. STREET AND NUMBER
<br />e. APT. NO.
<br />9f. ZIP CODE
<br />9g. INSIDE CITY LIMITS
<br />a
<br />4005 Indianhead Drive
<br />68803
<br />® YES ❑ NO
<br />M
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />10b. NAME OF SPOUSE (Flrst, Middle, Last, Suffix) If wife, give maiden name
<br />C
<br />d
<br />❑ married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />Veronica Almeida
<br /><
<br />11. FATHER'S -NAME (.First, Middle, Last, Suffix)
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Frank Bilotta
<br />Avis Beryl
<br />E
<br />E
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Ves.
<br />14a. INFORMANT -NAME
<br />14b. RELATIONSHIP. TO DECEDENT.
<br />0
<br />(Yes, No, or Unk.) Yes 01 /10/1969-12/04/1987
<br />Veronica Bilotta
<br />Spouse
<br />.8
<br />15. METHOD OF DISPOSITION
<br />16a. EMBALMER -SIGNATURE
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />I0
<br />❑Burial ' ❑ Donation
<br />I
<br />Not Embalmed
<br />April 2, 2018
<br />® Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska CremationServices Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />la. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street. Grand Island. Nebraska
<br />68801
<br />CAUSE OF DEATH See instructions and examples)
<br />1a. PART 1. Enterthe chain of events --diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a fine. Add additional lines if necessary.
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Final a) Coronary Artery Disease ; Years
<br />disease or condition resulting
<br />in death)
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Sequentially list conditions, if '. b) Generalized Atherosclerosis ; Years
<br />any,. leading to the cause listed
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE C)
<br />li iseakeor injurythat initiated
<br />the events resultjna in death) DUE TO, OR AS A CONSEQUENCE OF: onsetto 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
<br />I. 19. WAS MEDICAL EXAMINER
<br />DM, PVD, Rhabdomyolysis, CVA
<br />OR CORONER CONTACTED?
<br />Ir
<br />W
<br />❑ YES' ® NO
<br />M
<br />20. IF FEMALE:
<br />21a. MANNER OF DEATH
<br />21b. IF TRANSPORTATION INJURY 21c.
<br />WAS AN AUTOPSY PERFORMED?
<br />P
<br />n Not pregnant within past year
<br />® Natural ❑ Homicide
<br />❑ Driver/Operator
<br />❑YES ®NO
<br />W
<br />L)
<br />❑ Pregnant at time of death
<br />❑ Accident ❑ Pending Investigation
<br />Passenger
<br />❑ g
<br />WERE AUTOPSY FINDINGS AVAILABLE
<br />❑ Not pregnant, but pregnant within 42 days of death❑
<br />-
<br />Suicide Could not be determined
<br />❑ ❑
<br />Pedestrian 21d.
<br />,.
<br />Q Not pregnant, but pregnant 43 days to 1 year before death
<br />: :
<br />❑ 011ier (Specify)
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ Unknown it pregnant within the past year
<br />❑ YES ❑;e, NO
<br />E
<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 />0
<br />v
<br />I
<br />M
<br />22d. INJURY AT WORK? -
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />1Q
<br />DYES ❑ NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APTAO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />Z'>
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />o ac
<br />March 29. 2018
<br />o s Z
<br />23h. DATE SIGNED (Mo., Day. Yr.! _T23,_. TIME OF DEATH
<br />24c, PRONOUNCED DEAD (Mo, Day, Yr.)
<br />24d. TIME PRONOUCSED DEAD
<br />Y P }
<br />Y F >
<br />U z
<br />I Aril 6 2018 07:05 AM
<br />E o a z
<br />O
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />On the basis of examination and/or investigation, in my opinion death occurred at
<br />uO
<br />'o' w 24e.
<br />0 o
<br />and due to the cause(s) stated. (Signature an, Ttle)
<br />c 0 0
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />~
<br />Shawn S. Lawrence, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />26b. WAS CONSENT GRANTED4
<br />❑ YES ❑ NO ® PROBABLY ❑ UNKNOWN
<br />I ❑ YES ® NO
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Shawn S. Lawrence, MD, 2201 N Broadwell Ave., Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />_
<br />April 6, 2018
<br />
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