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THIS DOCUMENT HAS A LIGHT BACKGROUND ON TRUE WATERMARKED PAPER. HOLD TO LIGHT TO VERIFY FLORIDA WATERMARK. BUREAU of VITAL STATISTICS CERTIFICATION OF DEATH 201902494 STATE FILE NUMBER: 2016174831 DECEDENT INFORMATION NAME: ROGER LOUIS OTTE DATE ISSUED: November 28, 2016 STATE FILE DATE: November 23, 2016 DATE OF DEATH: November 22, 2016 SEX: MALE SSN: 505-52-5101 AGE: 084 YEARS DATE OF BIRTH: November 16, 1932 BIRTHPLACE: SWEETWATER, NEBRASKA, UNITED STATES PLACE OF DEATH: INPATIENT FACILITY NAME OR STREET ADDRESS: HEALTH CENTRAL L.00AriO,d OF DEATH: OCOEE, ORANGE COUNTY, 34761 SURVIVING SPOUSE, DECEDENT'S RESIDENCE AND HISTORY INFORMATION MARITAL STATUS: MARRIED SURVIVING SPOUSE NAME: ARDIS EILEEN FINWALL RESIDENCE: 2310 N. HUSTON AVENUE, GRAND ISLAND, NEBRASKA 68803, UNITED STATES COUNTY: HALL OCCUPATION, INDUSTRY: PRODUCTION, MANUFACTURING RACE: x White _Black or African American _Asian Indian _Chinese _Filipino _Native Hawaiian _Japanese _Korean American Indian or Alaskan Native --Tribe: __Vietnamese _Other Asian: _Guamanian or Chamorro Samoan _Other Pacific Isl:Other: _Unknown HISPANIC OR HAITIAN ORIGIN? NO, NOT OF HISPANIC/HAITIAN ORIGIN EDUCATION: HIGH SCHOOL GRADUATE OR GED COMPLETED EVER IN U.S. ARMED FORCES? YES PARENTS AND INFORMANT INFORMATION FATHER/PARENT: LOUIS MARTIN OTTE MOTHER/PARENT:SYLVIA ROSE BERZINA INFORMANT: ARDIS OTTE RELATIONSHIP TO DECEDENT: WIFE INFORMANTS ADDRESS: 2310 N. HUSTON AVENUE, GRAND ISLAND, NEBRASKA 68803, UNITED STATES PLACE OF DISPOSITION AND FUNERAL FACILITY INFORMATION PLACE OF DISPOSITION: WESTLAWN MEMORIAL PARK GRAND ISLAND, NEBRASKA METHOD OF DISPOSITION: REMOVAL FROM STATE FUNERAL DIRECTOR/LICENSE NUMBER: CONCETTA D. CARLSON, F042399 FUNERAL FACILITY: WOODLAWN FUNERAL HOME F040201 400 WOODLAWN CEMETERY RD, GOTHA, FLORIDA 34734 CERTIFIER INFORMATION TYPE OF CERTIFIER: CERTIFYING PHYSICIAN MEDICAL EXAMINER CASE NUMBER: NOT APPLICABLE TIME OF DEATH (24 hr): 0053 DATE CERTIFIED: November 23, 2016 CERTIFIER'S NAME: ROSHAN ASHOKKUMAR PATEL CERTIFIER'S LICENSE NUMBER: ME126966 NAME OF ATTENDING PHYSICIAN (If other than Certifier): NOT APPLICABLE CAUSE OF DEATH AND INJURY INFORMATION MANNER OF DEATH: NATURAL CAUSE OF DEATH - PART I - and Approximate Interval: Onset to Death: a CA{4.9.e`CENIC SHOCK b ST ELEVATION MI c CAD S/P CABG d PART II - Other significant conditions contributing to death but not resulting in the underlying cause given in PART I: ACUTE RENAL FAILURE, DIC,SHOK LEVEL, ASPIRATION PNEUMONIA AUTOPSY PERFORMED? NO AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? DATE OF SURGERY: DID TOBACCO USE CONTRIBUTE TO DEATH? YES REASON FOR SURGERY: IF FEMALE, NOT APPLICABLE DATE OF INJURY: NOT APPLICABLE TIME OF INJURY (24 hr) INJURY AT WORK? LOCATION OF INJURY: DESCRIBE HOW INJURY OCCURRED: PLACE OF INJURY: IF TRANSPORTATION INJURY, Status of Decedent: Type of Vehicle: ,State Registrar REQ: 2017596755 THE ABOVE SIGNATURE CERTIFIES THAT THIS IS A TRUE AND CORRECT COPY OF THE OFFICIAL RECORD ON FILE IN THIS OFFICE. THIS DOCUMENT IS PRINTED OR PHOTOCOPIED ON SECURITY PAPER WITH WATERMARKS OF THE GREAT WARNING: SEAL OF THE STATE OF FLORIDA. DO NOT ACCEPT WITHOUT VERIFYING THE PRESENCE OF THE WATER- MARKS. THE DOCUMENT FACE CONTAINS A MULTICOLORED BACKGROUND, GOLD EMBOSSED SEAL, AND THERMOCHROMIC FL. THE BACK CONTAINS SPECIAL LINES WITH TEXT. THIS DOCUMENT WILL NOT PRODUCE A COLOR COPY. I I i III lillilfil III I I I I * 5 5 4 5 6 2 3 3* DH FORM 1947 (03-13) ,CERTIFICATION OF VITAL RECORD;; arida HEALTH :