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f��,illa� t,1? 31$'ttitt•AmiliZs:mayteiZ4341 i1i4 elii: z / ttWDJAAtR x Y fk16tATISfktAAcss� c fxtyASVNA > rfkt6tttiiitAftASc?x' fr6r4t�u, ��Atit} 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 1/11/2021 LINCOLN, NEBRASKA 202106734 )r ( I'd r )rr, ..t7 Ki x4 tP rrt_ SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 20 19341 al E 1. DECEDENTS -NAME (First, Middle, Last, Suffix) David Wayne Kolbet 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Greece 5a. AGE - Last Birthday (Yrs.) 63 5b. UNDER 1 YEAR 2. SEX Male 5c. UNDER 1 DAY MOS. DAYS HOURS MINS. 3. DATE OF DEATH (Mo., Bay, Yr.) December 30, 2020 6. DATE OF Wit{ Day, Yr.) • July 29, 1957 7. SOCIAL SECURITY NUMBER 505-82.2317 Bb FACILITY -NAME (If not Institution, give street and number) VA Medical Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Omaha 68105 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 423 East Stoiley Park Road 9b. COUNTY Hall lOa. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married ❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Arthur Raymond Kolbet 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 05/07/1982-05/31/1999 15. METHOD OF DISPOSITION Burial ❑ Donation 0 Cremation 0 Entombment 0 Removal 0 Other (Specify) 8a. PLACE OF DEATH HOSPITAL M Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island OTHER ❑ Nursing Home/LTC 0 Decedent's Home ❑ Other (Specify) I8d. COUNTY OF DEATH Douglas Be. APT. NO. 9f. ZIP CODE 68801 ❑ Hospice Facility 9g. INSIDE CITY LIMITS YEs ❑ Aro. 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Diane Prichard 14a. INFORMANT -NAME Diane Kolbet 16a. EMBALMER -SIGNATURE Katie M. Smvdra 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Marqaret McIntyre 16b. LICENSE NO. 1454 14b. RELATIONSHIP TODECEDENT Spouse 16c. DATE (Mo., Day, Yr.) January 2. 2021 16d. CEMETERY, CREMATORY OR OTHER LOCATION Parkview Cemetery 17e. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska CITY / TOWN Hastings CAUSE OF DEATH (See instructions and examples) ta. PART I. Enter the chain of events- diseases, injuries, or complications4hat 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) Obstructive Shock IMMEDIATE CAUSE (final diaeese of condition resulting In death) Sequentially list conditions, if any, leading to the causelisted on Eta a. Enter the UNDERLYING CAUSE (disease or injury that ifntieted the events resulting in death) LAST STATE Nebraska 17b. Zip Code 88801 APPROXIMATE INTERVAL onset to death 6 Hours DUE TO, OR AS A CONSEQUENCE OF: b)Pulmonary Embolism onset to death 6 Hours DUE TO, OR AS A CONSEQUENCE OF: c) COVID-19 Pneumonia onset to death 18 Days. DUE TO, OR AS A CONSEQUENCE OF: d) Chronic Obstructive Pulmonary Disease 18. PART Il. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I. Sleep Apnea, Diapetes Mellitus Type 2, Congestive Heart Failure, Chronic Kidney Disease 20. IF FEMALE: ❑ Not pregnant within pest year El Pregnant at lime of death 0 Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑.Unknown Ifpregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? ❑YES ONO 21a. MANNER OF DEATH Natural 0 Homicide ❑ Accident 0 Pending Investigation ❑ Suicide ❑ Could not be determined 22b. TIME OF INJURY 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger 0 Pedestrian ❑ Other (Specify) onset to death >5 Years 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED?' ❑ YES ®NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ®NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ N4 ... 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, ate. (Spec) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATIONIOF INJURY STREET & NUMBER, APT.NO. CITY/TOWN z 0 23a. DATE OF DEATH (Mo., Day, Yr.) December 30, 2020 23b. DATE SIGNED (Mo., Day, Yr.) January 5 202 23e. TIME OF DEATH 06:11 AM 23d. To best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Lee M. Morrow, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? YES Q NO ❑ PROBABLY 0 UNKNOWN STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH YIP CODE 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and/or investiga Ion, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title)<: 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ®NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Lee M. Morrow, MD, 4101 Woolworth Ave, Omaha, Nebraska, 68105 28a. REGISTRAR'S SIGNATURE , 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) January 6, 2021 i CD ( (�0 �. D