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<br />STATE OF NEBRASIA
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<br />THIS COPYCARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />IRA TRUECOPYOFTRE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, ViTAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />8/28/2026
<br />LINCOL-N, NEBRASKA_
<br />2026O6031
<br />a'1t
<br />SARAH BOIINENKAMP
<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 -DECEDENT'S I.AME (FIrst Middle, Last, Suffix)
<br />Edw.in James Maslonka
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />FulJert4n, Nebraske::.
<br />sticr L SECtri in ama ER
<br />507464 9072,
<br />Sit FACILITY -NAME (If not Intditution, give street and number)
<br />$25;Delaware Ave
<br />Bc CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grant:Ward 68801
<br />ea, RESIDENCE -STATE
<br />]Nebraska
<br />9 • $IREEl'AN J NUMBER'
<br />825 DelaWaae Ave
<br />9b.000NTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Marrled, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />11 FATHER'S NAME (First, ::. Middle, Last, Suffix)
<br />Joe Masnka
<br />13. EVER i9 U.S ARMRb FORCES?
<br />(Yes, No, or Una.) No
<br />MEtHOD.OF esebeITtON
<br />�BuAal Donation:.
<br />Cl Crafeeiton ❑ Entombment
<br />❑ Removal Q Other (Specify)
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />81
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />i
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7
<br />26 I
<br />3. DATE OF DEATH Okh, Dap Yr ):
<br />August 19, 2022E
<br />8. DATE OF ORTN (M
<br />August 17,`1
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient /OTHER 0 Nursing Hoots/LTC
<br />J
<br />❑ ER/Outpatient
<br />© DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />~ ® Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />IN. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />10 NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Teri Noble
<br />14a. INFORMANT -NAME
<br />Terri Maslonka
<br />18a. FUNERAL DIRECTOR SIGNATURE
<br />Leslie M. Solt
<br />12. MOTHER'S -NAME (First, Middle, Maiden Sumanie)
<br />Monica Unknown
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Fullerton Cemetery
<br />!7a FUNERAL so . E'NAME;:AND MAILING ADDRESS (Street, City or Town, State)
<br />Cit•Wagner Funera#'Home, 1507 17th Street, Central City, Nebraska
<br />ta. PART I. Enter the chain of
<br />1"ei !"1 ariei{t
<br />gAMEM TE CAUSE kgt
<br />dielicatercatelfilteresia
<br />18b. LICENSE NO.
<br />1398
<br />CITY / TOWN
<br />Fullerton
<br />CAUSE OF DEATH (See instructions and exam les)
<br />events. -diseases, injuries, or complications -that directly caused the death. DO/NOT enter terminal events such(as cardiac wrest,
<br />ntriculer fibrillation without showing the etiology. DO NOT ABBREVIATE, Enter only one cause on a line. Add additional 1171 If necessary.--
<br />iMMEDIATE CAUSE:
<br />1)Cardio-Pulmonary Arrest
<br />in dual) DUE TO, OR AS A CONSEQUENCE OF:
<br />ioueMi.Fi.fy hat conditions, if b)
<br />#ay .Nailing to tM:ciwse 9atwr.
<br />OR AS A CONSEQUENCE OF:
<br />Enter eRLVINP CAUSE . leiSE
<br />lasses or Injury thatanaieted
<br />the events resulting in duth j DUE TO, OR AS A CONSEQUENCE OF:
<br />18 PART IL SIGNIFICANT CONDIT,ONS-Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Protein CalorieER Malnutrition, Weight Lbss, Hypertension, Pulmonary Hypertension,
<br />2O IF (MALE
<br />Net pre nesaatihla peat year
<br />F!tf gem* inns of death
<br />Not laegmnt, but pregnant within 42 days of death
<br />pregnant, bat pregnant 42.days to 1 year before death
<br />tigknown jr 10pnarit wWiin its PRO year
<br />I`4 URY(Mo.::Day,Yf.)7
<br />2241. DATE,ItF
<br />RY AT WORK?
<br />YES ONO
<br />21a. MANNER OF DEATH
<br />Ea Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />© On./Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />o., Day, Yr.)
<br />Hospice FlclUtyi
<br />14b. RELATlON$HIFI'ODECI
<br />Spouse
<br />180. DATES tMJ1.19. t)
<br />August 29;1026;
<br />21 c. WAS AN AUTOPSY:PERF
<br />❑ YES
<br />21d. WERE AUTOPSY INNOINOS AYAIWE
<br />TO COMPLETE CAUSE OF IMAM
<br />❑ via
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building,
<br />22s. DESCRIBE HOW INJURY OCCURRED
<br />22f LOCATION OFJN,Ii)NY:*STREET& NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August,19 2026
<br />2db DATE SIGNED (Mo., Day, Yr.)
<br />AMMO 24<.2026
<br />23c. TIME OF DEATH
<br />11:55AM
<br />*3d ToithS isdt'iif riiy Niowledge, death occurred at the time, date and place
<br />and'Que to ttti'ceuseis) stated. (Signature and Title)
<br />Heather M. Fago, MD
<br />#OACc. A,Pli 1' RIf3UTE TO THE DEATH?
<br />I� NO U'PROBABLY ® UNKNOWN
<br />MR
<br />zli
<br />f
<br />U
<br />U
<br />STATE
<br />24a. DATE SIGNED (Mo., Day,Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATN ;'
<br />24d. TIME PRO
<br />Z#P QODE
<br />24e. On the bests of examination and/or Investigation, in my opinion AelBi:aliment
<br />the time, date and place and due to the meets) stated. (sigretnre --
<br />2!". HAS HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ONO
<br />27 t 0411.E.; .,.ND DDREStI OF CERTIFIER (Type or Print
<br />Heather M: Fago, MD 205 S Linc9ln Ave Ste 101, York, Nebraska,
<br />2eb. WAS CONSENTGRAintbS.
<br />Not Applicable If 28a Is NO I
<br />28b. DATE FILED BY RCS
<br />August 26, 2026
<br />
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