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J4o 011 1,rttttG7tLI12[4.Ktpt' UIRITAm.Iii':t1ctA11y1W.57NBildoidatinflfa 1„ -- 64;itt4TtYYtt)ta?1d,�,�.,.. /2dYi'pd4MAa :. EYtitr19!�iP.l?'o.x �_' 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 7/7/2020 LINCOLN, NEBRASKA 202005088 �1'5/4 p �^44 rtC SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 20 08468 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Darrell Lee Penes 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Ord, Nebraska 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) June 9, 2020 5a. AGE - Last Birthday (Yrs.) 65 5b. UNDER 1 YEAR 5c. UNDER 1 DAY MOS. DAYS HOURS MINS. 6. DATE OF BIRTH (Mo., Day, Yr.) 7,.8OCIAL SECURITY NUMBER 506-72-9153 8b.::FACtLITY.NAME (1# not Institution, give street and number) UNMC 8c..CITY OR TOWN OF DEATH (Include Zap Code) :Omaha. 68198 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 1516 N. Kruse Ave: 9b. COUNTY Hall 811. PLACE OF DEATH HOSPITAL rE Inpatient ❑ ER/Ou patient ❑ DOA 10s MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Elmer Penes 9c. CITY OR TOWN Grand Island August 21, 1954 OTHER 0 Nursing Home/LTC 0 Decedent's Home ❑ Other (Specify) I8d. COUNTY OF DEATH Douglas 9e. APT. NO. 9f. ZIP CODE 68803 ❑'Hospice Facility 9g. INSIDE CITY LIMITS' O'YES ❑'NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Pamela Kehm 1 12, MOTHER'S -NAME (First, Marian Skala Middle, Maiden Surname) 13. EVER IN US. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unit.) Yes 07/25/1973-12/23/1975 14a. INFORMANT -NAME Pamela Penas 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial 0 Donation 0 Cremation 0 Entombment Removal ❑ Other (Specify) 16a. EMBALMER -SIGNATURE Rebecca S. Unger 16d. CEMETERY, CREMATORY OR OTHER LOCATION 16b. LICENSE NO. 1518 CITY / TOWN Central Nebraska Cremation Services Gibbon 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska CAUSE OF DEATH (See instructions and examples) 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, 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: a/Acute Hypoxic Respiratory Failure IMMEDIATECAUSE(Fbtat Biases. or condaion naysing: In attain sequentially list conditions, if any, leading to the cause listed on a Enter the UNDERLYING CAUSE (diaeaea or injury that kldieted the events resulting in death) LAST DUE TO, OR AS A CONSEQUENCE OF: b)Septic Shock DUE TO, OR AS A CONSEQUENCE OF: c) Post-obstructive Pneumonia 16c. DATE (Mo., Day, Yr.) June 13, 2020 STATE Nebraska 17b. Zip Code 68801 APPROXIMATE INTERVAL onset to death Hours onset to death Hours onset to death Days DUE TO, OR AS A CONSEQUENCE OF: d)Non-small Cell Lung Cancer Of The Right Lung onset to death Months 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I. Hyponatrerria, Dysphagia 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES E NO 20. IF FEMALE: Not pregnant within past year Q Pregnant at time Of death 0 Net pregnant, ',taprooms 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 21a. MANNER OF DEATH E Natural Homicide 0 Accident ❑ Pending Investigation 0 Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑YES ENO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a DATE OF'IINJURY (M9 Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, fart, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f LOCATION OF INJURY STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) June 9, 2020 23b. DATE SIGNED (Mo., Day, Yr.) June 11,!2020 23c. TIME OF DEATH 01:23 AM ad. Td the beet of My knowledge, death occurred at the tkns, date and place aid due 10 the sause(s) stated. (Signature and Title) Bronwyn L Small, MD 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the causes) stated. (Signature end Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES 0 NO : 0 PROBABLY 0 UNKNOWN 27. NANO, TITLE AND ADDRESS OF CERTIFIER (Type or Print Bronwyn L Small, MD, 985910 Nebraska Medical Center, Omaha, Nebraska, 68198 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ;7 NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a ie NO OYES ❑ NO 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) July 1, 2020 CYN Ln (