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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 12/3/2018 LINCOLN, NEBRASKA 201903817 RUSSELL FOSLER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Wendell Lee Novotny 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) November 24, 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.) 60 MOS. DAYS HOURS MINS. September 8, 1958 7. SOCIAL SECURITY NUMBER 507-76-6171 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 0 EFL/Outpatient 0 Decedent's Home 0 DOA ❑ Other (Specify) '8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall Pursuant to section 30-2413, demands for notice which may affect the estate of the dec Tased are filed with the county court in the county where the decedent resides *P. RESIDEN'It.CTfTE 19h. COUNTY Nebraska 1 Hall 9c CITY OP TOWN Grand Island 9d. STREET AND NUMBER 112 W. 21st 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated 0 Widowed 0 Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Anna Carter 11. FATHER'S -NAME (First, Middle, Last, Suffix) Alfred Novotny 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Gloria Svoboda 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Anna Novotny 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial 0 Donation 16a. EMBALMER -SIGNATURE William D. Greenwav 16b. LICENSE NO. 0913 16c. DATE (Mo., Day, Yr.) November 28, 2018 ❑ Cremation 0 Entombment ❑ Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Elba Cemetery Elba Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Jacobsen-Greenwav Funeral Home. 411 0 Street, PO Box 112. St. Paul, Nebraska 17b. Zip Code 68873 CAUSE OF DEATH (See instructions and examples) 111. 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 if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE Winal a) Roc_niratnry Fpili,rA disease or condition resulting onset to death 2 Dcys in death) DUE TO, OR AS A CONSEQUENCE OF: sequentiaaylist condittmia,if ;-:: b)Metastatic Lung Cancer e y, lifea :4 ,. W aareu onset to death 3 Months on linea::: DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury that initiated onset to death the events resulting Nt 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 1. Cirrhosis, Polycystic Liver Disease 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? 0 YES ® NO 20. IF FEMALE: 0 Not pregnant within past year 0❑Pregnant at time of death❑ 21a. MANNER OF DEATH ® Natural ❑ Homicide Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ®NO ❑ Not pregnant, btd pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death 0 unknown if pregnant within the past year 0 Suicide 0 Could not be determined 0 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? 0YES NO Q 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) November 24, 2018 To be coml feted by CORONER'S PHYSICIAN or COUNTY b TTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) Novernoer 27, 2018 23c. TIME OF DEATH 1 12:24 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Isaac J. Berg, 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) 85. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES 0 NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803 ,,,,, 28a. REGISTRAR'S SIGNATURE C___-------- - �T 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) November 28, 2018 ©``" `"�-