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Yr • 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 IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 1/16/2019 LINCOLN, NEBRASKA RUSSELL 201902577 ASSISTANT STATEE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1813270 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. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Brenton Elliott Wysocki 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) October 13, 2018 4. CITY AND 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.);, Grand Island, Nebraska (Yrs.) 31 MOS. DAYS HOURS MINS. July 26, 1987 7. SOCIAL SECURITY NUMBER 505-19-9635 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street end number) 402 South Cherokee Avenue 0 ER/Out. atie:lt E Decedents Horne 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 402 South Cherokee Avenue 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS' ® YES 0 NO 105. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married ❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Kimberly Ann Lech 11. FATHER'S -NAME (First, Middle, Last, Suffix) Roger Kent Wysocki 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Kathryn Marie Gregoski 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or link.) No 14a. INFORMANT -NAME Kimberly Ann Wysocki 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial 0 Donation 16a. EMBALMER -SIGNATURE Mark Roper 16b. LICENSE NO. 1112 16c. DATE (Mo., Day, Yr.) October 18, 2018 ❑ Cremation 0 Entombment 0 Removal 0 other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE Ord City Cemetery Ord 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. Enter the chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, ' APPROXIMATES INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines H necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Positional Asphyxia Due To External Compression Of The Neck disease or condition ,suiting onset to death Minutes n death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, ,f :. b) any, Watling to the cause listed" line onset to death on a. DUE TO, OR AS A CONSEQUENCE OF: Enter INC UNDERLYING CAUSE c) /disease or injury that initiated ih onset to death the events resulting in oath) :. DUE TO, OR AS A CONSEQUENCE OF: LAST ': d) onset to death. 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Obesity; Artherosclerotic Heart Disease; Fatty Liver; Toxic Effects Of Hydrocodone 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? E YES 0 NO 20. IF FEMALE: 0 Not pregnant within past year 0 Pregnant at time of death 21a. MANNER OF DEATH 0 Natural ❑ Homicide E Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator Passenger 21c. WAS AN AUTOPSY PERFORMED? E YES ❑ NO 0 Not pregnant, but pregnamwithin 42 days of death 0 Not pregnant, but pregnant, 43 days to 1 year before death 0 Unknown ,f pregnant within the past year ❑ Suicide ❑ Could not be determined 0 Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH'? E YES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.) October 13, 2018 22b. TIME OF INJURY Unknown 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) Home 22d. INJURY AT WORK? ❑YES 1 No 22e. DESCRIBE HOW INJURY OCCURRED Decedent had a recent surgery and went to sleep in a spare room, he was found unresponsive face down with his head nvpr/in a trash ran 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 402 South Cherokee Avenue, Grand Island Nebraska 68803 To be completed by.. MEDICAL CERTIFIER. ONLY 235. DATE OF DEATH (Mo., Day, Yr.) To be completed by CORONERS PHYSICIAN or COUNTY ATTORNE. Y ONLY 24a. DATE SIGNED (Mo., Day, Yr.) October 17, 2018 24b. TIME OF DEATH Unknown 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) October 13, 2018 24d. TIME PRONOUNCED DEAD 09:03 AM 3d. To the best of my knowledge, death occurred at the time, date and place and due to Um cause(s) stated. (Signature and Title) 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 Title) Sarah Carstensen, Hall County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES ❑ NO 0 PROBABLY E UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? 0 YES E NO � Not Applicable if 26a is NO 0 YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Sarah Carstensen, Hall County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801 28a. REGISTRAR'S SIGNATURE / -- 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 18, 2018