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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 />1219/2019
<br />UNCOLN, NEBRASKA
<br />202001577
<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 />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Gary Stanley Spotanski
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November 29, 2019
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Loup City, Nebraska
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />71
<br />8b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day,Yr.)
<br />January 29, 1
<br />948
<br />7. SOCIAL SECURITY NUMBER
<br />505-64-1322
<br />8b. FACILITY -NAME (If notinstitution, give street and number)
<br />CHI Health St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />94. RESIDENCE -STATE 9b. COUNTY
<br />Nebraska Hall
<br />3016 Brentwood Blvd
<br />19a. MARITAL STATUS AT TIME OF DEATH I] Married 0 Never Married
<br />❑Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />E ER/Outpatient
<br />❑ DOA
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />{ 9c. CITY OR TOWN
<br />,I Grand Island
<br />18a. VT ::^. l if ZIP CODE
<br />10b. NAME OF SPCUSE (Fi'
<br />PA Ula rsolsOn
<br />68801
<br />0 Hospice Facility
<br />193. tovDE CITY t:1MiT$
<br />I;l YES ❑ NO
<br />Middle, Last, Suffix) If wife, give maiden name
<br />It '1 i. FA'THER'S -NAME (First, Middle, Last, Suffix)
<br />3 Stanley Spotanski
<br />g
<br />O
<br />u
<br />12. MOTHER'S --NAME (First,
<br />Helen Karslon
<br />Middle, Maiden Surname)
<br />13. EVER IN U.S.; ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unt) Yes 02/19/1968-02/12/1972
<br />14a. INFORMANT -NAME
<br />Paula Spotanski
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF tasPOSTION
<br />E Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />Removal © Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCoy
<br />16b. LICENSE NO.
<br />1191
<br />16c. DATE (Mo., Lay Yr.)
<br />December 5, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />c 17a. FUNERAL 1413ME NAME AND MAILING ADDRESS (Street, City or Town, State)'
<br />c Aofel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />u
<br />0
<br />.c
<br />d
<br />M
<br />3
<br />N
<br />O
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />'IL PAPARTL Enter the Chin of evh}e tits- -diseases, Injuries, or complications -that directly ciliated the death, 00 NOT enter terminal svems such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Einar only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Acute Cardiac Arrest
<br />disuse or condition resulting
<br />in:death)
<br />Segnentlally Mat 4endisoMe, if
<br />any, leading to the cause listed
<br />on line a
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury that Initiated:<
<br />jn death)
<br />Me evetas tI*l Itt
<br />LAST
<br />13) Cause Unknown
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />STATE
<br />Nebraska
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Minutes
<br />onset to death
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death hut not resulting in the underlying cause given in PART I.
<br />20.1F FEhIALE:
<br />O Not pregnantwithin past year
<br />o Pregnant at time of death
<br />❑ NSM pfepnany ilut pregnant wlthin 42 days of death
<br />❑ N propMnt, but pragpant ad days tot year before death
<br />❑ Uehrinere N./ r -a ts'..n^.' :^' ,,,et f
<br />22& DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES ONO
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION
<br />Driver/Operator
<br />0 Passenger
<br />Pedestrian
<br />o other (apathy)
<br />INJURY
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />E YES ❑ NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES E NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE QF DEATH?
<br />I❑
<br />`..'ES 0Ft
<br />22c. PLACE OF INJURY -At home, fann, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />CITYITOWN
<br />STATE
<br />ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the ousels) stated, (Signature and Tale)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />December 6, 2019
<br />24b. TIME OF DEATH
<br />07:15 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />November 29. 2019
<br />24d. TIME PRONOUNCED DEAD
<br />07:15 PM
<br />24e. On the basis of examination and/or investigation, In my opinion death occurred at
<br />she time, date and place and due tote ousels) stated. (Signature and Tide)
<br />Katherine J. Doering, Deputy County Attorney
<br />25. r ID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR riSSuE OoNATIoN BEEN CONSIDERED?
<br />❑ YES 0 NO 0 PROBABLY E UNKNOWN ❑ YES In NO
<br />27. NAM, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Katherine J, Doering, Deputy County Attorney, 231 South Locust, Grand Island, Nebraska, 68801
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES 0 NO
<br />28a.;RBGISTRAk!'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo.r Day, Yr.)
<br />December 9, 2019
<br />
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