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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 5/28/2010 LINCOLN, NEBRASKA 201903843 MEL!, FOSIER ASSISTANT STATE REGISTRAR DEPARTMENT OF DEALT!) AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OP HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Pursuant to section 394413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent fesided at the time of death. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Jerome Jay Cochnar 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) May 9, 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.) Grand Island, Nebraska (Yrs.) 51 MOS. DAYS HOURS MINS. January 10, 1968 7. SOCIAL SECURITY NUMBER 506-72-8347 8a. PLACE OF DEATH HOSPITAL RI Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility Sb. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 0 ERJOutpatient 0 Decedent's Home 0 DOA 0 Other (Specify) Sc. CITY OR TOWN OF DEATH (Include Zip Cods) Grand Island 88803 ad. COUNTY OF DEATH Hall 9e. RESIDENCE -STATE Nebraska lib. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 517 W 5th St 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES 0 NO We. MARITAL STATUS AT TIME OF DEATH 0 Married E Never Married 0 Married, but separated 0 Widowed ❑ Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname) James F Cochnar Anna Mae Carkoski 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yee, No, or Unit.) No 14a. INFORMANT.NAME Ann Marie Kahle 14b. RELATIONSHIP TO DECEDENT Sister 15. METHOD OF DISPOSITION ® Burial 0 Donation 16a. EMBALMER -SIGNATURE Matthew T. Myers 16b. LICENSE NO. 1411 16c. DATE (Mo., Day, Yr.) May 16, 2019 ❑ Cremation 0 Entombment ❑ Removal 0 Other (Specify) 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE Westlawn Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND b A'LING ADDRESS (Street, City or Town, State) Livingston -Sondermann Funeral Home. 601 N. Webb Road, Grand Island. Nebraska 17b.Zlp Ccda 68803 CAUSE OF DEATH (See Instructions and examples) 1a.: PART I. Enter the chain of events- -di , Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL'. respiratory &neat, 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 (Final a) Hypoxia disease or condition resulting onset to death Hours In death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially fat conditions, it ", b) Cardiac Arrest any, leading to the cause fisted onset to death Minutes on line a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Ischemic Heart Disease waists or injury that initiated onset to death Years the 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. Morbid Obesity 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? 0 YES 1 NO 20. IF FEMALE: Q Not pregnant within past year ❑ Pregnant al time of death 2f1�af. MANNER OF DEATH Hal Natural 0 Homicide Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? 0 YES ®NO 0 Not pregnant, but pregnant within 44 days of death 0 Not pregnant, bid pregnant 44 days tot year before death ❑ Unknown H prynant with)ri the past year ❑ Accident 0 Q Suicide ❑ Could not be detsrrninad 0 Pedestrian 0 014. (50000 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 221. LOCATION OF INJURY- STREET i NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) May 9.2019', *Wsteab PHYSIcrw I ATTORNEY NLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) May 13, 2019 23e. TIME OF DEATH 04:25 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD ii 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) Anthony Cook`, 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? 0 YES ❑ NO 0 PROBABLY ® UNKNOWN 26a. HAS ORGAN OR SSUE DO ATION BEEN CONSIDERED? 0 YES El NO 26b. WAS CONSENT GRANTED'? Not Applh able If 28a is NO 0 YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print- rintAnthony Cook, MD, 555 South 70th Street, Lincoln, Anthony Nebraska, 68510 128a.',REGISTRAR'S SIGNATURE May 21, 2019 1,.,....:...o 1 .,., 01