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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 />2/7/2019
<br />LINCOLN, NEBRASKA
<br />20 ASSISTANT STATEREGISTRAR
<br />19 0 3 4 9 8
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Pur cant 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.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Carol L Nowka
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />February 4, 2019
<br />4. CITY AND
<br />STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />6a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Loup
<br />City, Nebraska
<br />(Yrs.)
<br />76
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />March 25, 1942
<br />7. SOCIAL SECURITY NUMBER
<br />508-52-5234
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER ® Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Good Samaritan Society -Grand Island Village
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other(Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE"
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />432 South Woodland Drive
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated RI Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Eldon W Nowka
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Roy V Alleman
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Irene G Miller
<br />13. EVER IN U.S, ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) No
<br />14a. INFORMANT -NAME
<br />Daryl Alleman
<br />14b. RELATIONSHIP TO DECEDENT
<br />Brother
<br />15. METHOD OF DISPOSITION
<br />?ural 0 Donation
<br />16a. EMBALMER -SIGNATURE 116b. LICENSE NO.
<br />Not Lii,uaince6 I
<br />16c. DATE (Mo., Day, Yr.)
<br />February 5, 2019
<br />® Cremation 0 Entombment
<br />0 Removal ; 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITU / TOWN STATE
<br />BV Cremation Center Hastings Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Livinaston-Butler-Volland Funeral Home, 1225 N. Elm. Hastinas. Nebraska
<br />17b. Zip Code
<br />68901
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the than of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Head And Neck Cancer Metastatic
<br />disease or condition resulting
<br />onset to death
<br />6 Months
<br />In death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading to the cause 8sted.
<br />line a.
<br />onset to death
<br />on
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />{disease OrInjury ',that initiated:
<br />onset to death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />d)
<br />onset to death
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF. FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />Passenger
<br />0
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />❑ ,Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days tot year before death
<br />0 :Unknown if pregnant within the past year
<br />Suicide Could not be determined
<br />❑
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home,
<br />farm, street, factory, office building,
<br />construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be completed by
<br />MEDICAL CERTIFIER.:.
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 4, 2019
<br />'7o be completed by
<br />COY.ONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />February 4, 2019
<br />23c. TIME OF DEATH
<br />02:00 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />1234. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature aid Title)
<br />Kya1 KamaeKers, 6.60
<br />24e. On the basis of examination end/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<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 ® 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 />Ryan Rarnaekers,MD, 2116 W. Faidley Avenue,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE Hyl +�"�`
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 6, 2019
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