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e._ ----Ye STATE OF NEBRASKA 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 5/3/2019 LINCOLN, NEBRASKA 201903420RUSSETA ASSISTANT STATEEREGISTRAR EGI ER DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 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) Allen Dale Rein 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) April 26, 2019 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday Sb. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) ,. Loup City, Nebraska (Yrs.) 80 MOS. DAYS HOURS MINS. May 3, 1938 7. SOCIAL SECURITY NUMBER 505-44-2817 8a. PLACE OF DEATH HOSPITAL © Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis ❑ ER/Outpatient 0 Decedent's Home ❑ DOA 0 Other (Specify) Sc. CITY OR TOWN OF DEATH (IDCiude 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 517 West 14th Street 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES 0 NO 10a.. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑'Married, but separated ❑ Widowed ❑ Divorced El Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Mary Jane Mendyk 11. FATHER'S -NAME (First, Middle, Last, Suffix) Percy A Rein 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Anna L Guzinski 13: EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 09/14/1956-09/13/1960 14a. INFORMANT -NAME Mary Jane Rein 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ®Burial ❑Donation 16a. EMBALMER -SIGNATURE Todd M Peters 16b. LICENSE NO. 1078 16c. DATE (Mo., Day, Yr.) May 2, 2019 ❑ Cremation 0 Entombment El Removal ❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Evergreen Cemetery Loup City Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Peters Funeral Home. 302 Second Street. PO Box 181, St. Paul. Nebraska 17b. Zip Code 68873 CAUSE OF DEATH (See instructions and examples) 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, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a)Aspiration pneumonia disoase x condition resuflna onset to death 3 Days in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if : b) Cerebrovascular disease any, leading to the cause listed on line a. - onset to death DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury that initiated onset to death me events resulting in death) 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. Failure to Thrive, Hyperlipidemia, Hypertension, Chronic Kidney Disease Stage 3, Systemic Lupus Erythematosus, Angioedema Carcinoid Tumor, Malnutrition 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? 0 YES Il NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death 21a. MANNER OF DEATH ® Natural ❑ Homicide 0 Aca:ent ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator l__I Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ; NG ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within She past year 0 Suicide ❑could not be determined ❑ Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 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) 22d. INJURY AT WORK? ❑'YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed t,y I MEDICAL CERTIFIER ONLY ,. J 23a. DATE OF DEATH (Mo., Day, Yr.) April 26, 2019 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) April 30, 2019 23c. TIME OF DEATH 03:00 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) Adam Brosz, 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 Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR SSUE DO ATION BEEN CONSIDERED? ❑ YES 7 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES El NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Adam Brosz, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803 _ 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I April 30, 2019 a/ r'-