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<br />WHEN THIS r 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 />8/8/2019
<br />LINCOLN, NEBRASKA
<br />201905361
<br />RUSSELL FOSLER
<br />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 />19
<br />Pursue It to section 30-2413, demands for notice which may affect the estate of the deceased are filed withthe county court in the county where the decedent resided at the time of death.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Maxon Eugene Stanislav
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 1, 2019
<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 />Central City, Nebraska
<br />(Yrs.)
<br />71
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />August 23, 1947
<br />7. SOCIAL SECURITY NUMBER
<br />507-66-9002
<br />8a. PLACE OF DEATH
<br />HOSPITAL © Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME (If riot Institution, give street and number)
<br />CHI Health St. Francis
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA ❑ Other(Specify)
<br />8c. CITY OR TOWN OF DEATH (include Zip Code! _. c,jty!T! r1F DEATH
<br />. a
<br />Grand Island 68803 I 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 />3204 Ponca Circle
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Linda Louise Power
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Joe Stanislav Jr
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Roselia McMahon
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, NO. or Unk.) Yes 04/07/1967-01/11/1973
<br />14a. INFORMANT -NAME
<br />Linda Louise Stanislav
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smydra
<br />16b. LICENSE NO.
<br />1454
<br />16c. DATE (Mo., Day, Yr.)
<br />August 6, 2019
<br />❑ Cremation 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING 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 />18. 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 />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines R necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Respiratory Failure
<br />disease or condition resulting
<br />onset to death
<br />Immediate
<br />ut death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially lett contSt.ordt, it h) Mstc:static Squarrous Cell 'Car 'iom2 Of H.`au .Arc Isle''.,
<br />any, leading to the cause listed
<br />iine
<br />onset to death
<br />MonUhS
<br />on a. --,
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) Pneumonia
<br />/disease or injury that initialeda
<br />onset to death
<br />Days
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<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 />Transitioned To Comfort Cares And Passed Away
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES ®NO
<br />20. IF. FEMALE:':.
<br />0 Not pregnant within past year
<br />Pregnant at time of death
<br />❑0
<br />21a. MANNER OF DEATH
<br />2 Natural 0 Homicide
<br />Accident ❑ Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />-
<br />❑ 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 />❑ Unknown If pregnant within the past year
<br />0 Suicide 0 Could not be determined
<br />0 Pedestrian
<br />0 Other (Speedy)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO 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?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />Tobi completed by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)Z
<br />August 1, 2019
<br />w
<br />a � z
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />August 2, 2019
<br />23c. TIME OF DEATH
<br />12:26 AM
<br />o s g
<br />o ; ; o
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />123d. To the hast of my knowledge, denim occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Michael A. Donner, MD
<br />K
<br />o
<br />. z p
<br />$ S
<br />?rip . •.... n.+!<...>-,-,,.••_- ,.,n:o- - - • _ .. �+ _
<br />the time, date and place and die to the cause(s) sr.ted. (Signature and Tit!
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY ® 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 ❑ YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Michael A. Donner, MD, 729 North Custer Avenue,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo, Day, Yr.)
<br />August 6, 2019
<br />,r7G°'T'y
<br />01
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