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<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 />9/5/2017
<br />LINCOLN, NEBRASKA
<br />201906457
<br />Coe
<br />STANLEY S. E(DOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />N+a4%"a /1i1't6i�ii3�ii�I�lA3.
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<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Donald Dean Penner
<br />4, CITY: AND STATE. OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Gage County, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />512-34-1575.
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />83
<br />Ott. FAC.RITY-NAME (If not Institution, give street and number)
<br />CHI Health' St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Lp Code)
<br />Grand Island 68803
<br />9a. RESIDENCE STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER'1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL %❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island'
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 18, 2017
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />August 21, 1933
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9d. STREET AND NUMBER
<br />2205 W. Phoenix Ave
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS"
<br />® YES ❑ NO
<br />10a. MARITAL STATUSAT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but Separated 0 Widowed 0 Divorced 0 Unknown
<br />Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Janet Diane Rhodes
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Paul Penner
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Anna Epp
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit.) No
<br />14a. INFORMANT -NAME
<br />Janet Diane Penner
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />® Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />August 23, 2017
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />First Mennonite Cemetery Beatrice
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />AH Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />te. PARTI. Einar the hain of events- diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<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) Aspiration Pneumonia
<br />disease or condition resulting
<br />in death]
<br />Sequentially est conditions, If
<br />any, loading to the cause (dated
<br />on line o.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Parkinson's Disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(dtseaeeor Injury that initiated
<br />11M events resaiting:in deaf.)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />Racoived Cy
<br />OCT 102017
<br />(Jnit
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Aortic Stenosis
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE 1NTERVAI.
<br />onset to death
<br />Days
<br />onset to death
<br />Years
<br />onset to death
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />Pregnant at time of death
<br />1:1
<br />ID
<br />NM{uegnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but prsgnam 43 days to 1 year before death
<br />❑ ipMmown if pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />Other (Specify)
<br />21 AS AN AUTOPSY PERFORMED? ®
<br />:YES NO
<br />.rev
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />'1110 COMPLETE CAUSE OF DEATH?
<br />O
<br />❑ YES ❑ NO
<br />21b. IF TRANSPORTATION INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office b , construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES ONO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />23A. DATE OF DEATH (Mo., Day, Yr.)
<br />•August 18, 2017
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Au • ust 22 2017
<br />23c. TIME OF DEATH .
<br />05:22 PM
<br />7d. To the best of my knowledge, death occurred at the rima, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Travis S, Hageman, MD
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.
<br />24d. TIME PRONOUNCED DEAD.
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Tide)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES j NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE;DONA110N BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />❑ YES I NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (MoDay, Yr.)
<br />August 29, 2017
<br />
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