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STATE OF NEBRASKA
<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 />9/28/2018
<br />LINCOLN, NEBRASKA
<br />201903062 INTERIM ASSISTANT STATE 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 sectiot 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 residedat the time of death.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Laurence DeWayne Otto
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />September 20, 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 />Doniphan, Nebraska
<br />(Yrs.)
<br />85
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />April 21, 1933
<br />7. SOCIAL SECURITY NUMBER
<br />506-36-8580.
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Prairie Meadows Alzheimer's Special Care Center
<br />0 ER/Outpatient ❑ Decedent's Home
<br />❑ DOA ® Other (Specify)ASSISTED LIVING
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 68164
<br />8d. COUNTY OF DEATH
<br />Douglas
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Douglas
<br />9c. CITY OR TOWN
<br />Omaha
<br />9d. STREET AND NUMBER
<br />13208 Meredith Ave
<br />9e. APT. NO.
<br />38A
<br />9f. ZIP CODE
<br />68164
<br />9g. INSIDE CITY LIMITS`
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Marilyn A Otto
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Rex John Henry Otto
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Helen Marjorie Burmood
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 114a. INFORMANT -NAME
<br />L (Yes, No, or Unk.) Yes .::04/12/1953-06/05/1953 1 Cindra Sue Hanssen
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />September 22, 2018
<br />®Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />11. 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 />retpiratoryarrett, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only onecause on; a line. Add additional lines 4 necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE �AUSy1'uwl a)Alzheimers Disease
<br />disease or condition resulting
<br />onset to death
<br />Years
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Seq.:entially hst conditions, if E b)
<br />any, leading to thecause fisted
<br />onset to death
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that initiated
<br />onset to death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LASTd)
<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 />Chronic Heart Failure
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />J YES 0 NO
<br />O. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />El Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ®NO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />-
<br />SideCould not be determined
<br />❑uic 0TO
<br />,: 0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />COMPLETE CAUSE OF DEATH?
<br />0 YES ❑ 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? :.22e.
<br />❑YES 0 N
<br />DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />lao.
<br />W
<br />nn,?sncncn,T'n",,,,:r.;
<br />September 20, 2018
<br />24d.OAito.VNCU(MO.,Uay,Yr.)
<br />e w
<br />a
<br />140.1iMtOFDEATH
<br />re >
<br />ti z
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />September 20, 2018
<br />23c. TIME OF DEATH
<br />09:50 AM
<br />o = G 24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />o
<br />24d. TIME PRONOUNCED DEAD
<br />a 0
<br />cand
<br />1,9
<br />2
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />due to the cause(s) stated. (Signature and Title)
<br />Rebecca M. Wester, MD
<br />'o+ w z 24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />g Z p the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />o O O
<br />~ s
<br />0'
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES El 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 />Rebecca M. Wester, MD, 4908 Cass St, Omaha,
<br />Nebraska, 68132
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 25, 2018
<br />28a. REGISTRAR'S SIGNATURE
<br />
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