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<br />STATE OF NEBRASKA -
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH.,�.4�11� HUMA�11� �ER,VICES, .t7" CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITM THE NEBRASl�11 C�F�F�A,I�T�1�'N�OF It1EALTH AND°� ''
<br />HUMAN SERVICES, VITAL REC�RDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR ,V:fTQ'L /Z��Q� � ;, „ a �, ,, �'
<br />, ; � ��. � ' �
<br />DATE OF ISSUANCE � ��/� `' ' ' , ;
<br />� ;� u .. i'
<br />05/19/2011 s�aNLEY s. �-ot�era ,
<br />2 012 0 0� 4 4 ASSI�s�J'��11�"��5,T1�7'� �2�G7S,77ZAR:. �� �, .;
<br />D,Ek►Al�`7MENT �F HEALTH ,4f1� y°'` x
<br />LINCOUV, NEBRASKA HU�jA�SEI�.t�CES: � + 5 :
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN 3ERVICES r �' ,�`"� �� �*� .�� ���✓ `
<br />.,� ,� • • - � , -� � 11 01659
<br />ctrciir��A�e�rur�in ° ,�, , �° s.
<br />1. DECEDENT'9-NAME (Flrat, Mlddie, Laet,, SuHix) 2. SDC "' '�' 3. DATE OF DEATH (Mo., Day, Yr.)
<br />Lo LaRee Wlnhey Female May 14, 2011
<br />4. CITY AND 3TATE OR TERRITORY, OR FOREI�N COUNTRY OF BIRTH 8a. AGE • Last BlRhday b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo„�Day, Yr.)
<br />(ti'�•) MOS. DAYS HOURS MIN9.
<br />Grand Island, Nebraska 73 July 1,1937
<br />7. SOCIAL SECURITY NUAABER Ba. PLACE OF DFATH
<br />507-4&6843 �� trmaueM 07'HER ❑ Nutai� Home/LTC � Hoaplee Fae11Qy
<br />Bb. FACILITY•NAME pf rrot Irretitutlon, ghe street and numbe� � ERIOulpaUerR ❑ DeeedaM's Home
<br />�
<br />� Salnt Francls Medical Center ❑ oon ❑ ot�,er (spedry)
<br />� Bc. CITY OR TOWN OF DEATH p�rclude Zip Code) Bd. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 9a. RESIDENCESTATE 9b. COUNTY 9c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />.7� 9d. STREET AND NUMBER 9e. APT. NO. 8f. ZIP CODE 8g. IIdSIDE CITY LIMITS
<br />�, 2215 West John 68803 � r�s ❑ No
<br />$ 10a. NWRITAL STATU9 AT TIdIE OF DEATH � Marrled � Never Mlarrted 10b. NAME OF SPOUSE (FUsy Middle, Last, Suffiz) If wHe, give maiden �me
<br />� ❑ mamed, But aeparatea ❑ vutaowed ❑ Oivorced ❑ urumown Jim D Winfrey
<br />� 11. FATHER'S•NAME (Flrst, Mtddle, Last, 3uffiu) 12. MOTHER'9-NAME (FUat, Middle, Malden Sumame)
<br />� Scott Barr Oral Coakley
<br />E 13. EVER W US. ARMED FORCES7 GNe dates of aervlee ITY�. 14a. INFORMANT•NAME 14b. RELATIONSMP TO DECEDENT
<br />g �res, Na, or uNc.� No Jim D Winfrey Husband
<br />,� 75. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 18c. DATE (Mo, Day, Yr.)
<br />F � Burial ❑ Dorwdon
<br />Derek Apfel 1240 May 18, 2011
<br />❑ Crematlon � Errtombmerd 78d. CEMETERY, CRENL4TORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removai ❑ otner (specrry� Grand I�land City Cemetery Grend Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRH89 (Street, Cily or Town, State) 176. Zip Cade
<br />Apfel Funaral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CA SE OF DEATH See nstructions and exam les
<br />te. PART L Enmr tire eham M events-�ui�see, inJuAea, or compueatio�that dlreWy caueed tlre tleath. DO NOT e�rter terminat eve� mich as caMae erteat, = APPROXINU►TE INTERVAL
<br />resplratory ertest, or verrtrteular Nbrplatlon wttl�out ahowi� tlre etlotog�r. DO NOT A6BREVIATE. Errter onty o�re muse an e Me. Add additlm�al Ihres Ii neceesary.
<br />re m
<br />IMMEDIATE CAUSE: or�set to death
<br />mn�ow�recauset� a)Respiratory Failure Wlth Pneumonia ; One Week
<br />dlse�e or coM@Inn r�uitfng =
<br />�n deathl DUE :O, OR AS A GON&ECUENCE OF: � o�et M aeath
<br />8equeMtaly Iist tondltlo�, H b) '
<br />e�ry, leading to the ca� Iiated �
<br />°� �� � DUE TO, OR AS A CON9EQUENCE OF: S orreet to death
<br />Frrter the UNDERLYINO CAUSE �� � �
<br />(dlsea� or InJury thet Inttlated
<br />tlre e"e"[e res"a�g M death� DUE TO, OR A9 A CONSEQUENCB OF: � or�set W death
<br />� d) ;
<br />18. PART 14 OTHER SIGNIFlCANT CONDITION3�CorMitlorm coritributl� to the death but not �u1ti� In tha wMertying cause given In PART I. 18. WAS [Y�DICAL EXANONER
<br />Underlying Chronic ObstrucUve Lung Disease OR CORONER CONTACTED7
<br />� ❑ vES p No
<br />W O. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TR/WSPORTATION INJUR 21e. WAS AN AUTOPSY PERFORMED9
<br />�
<br />� � Notprepnarrtwithlnpastyear � NaLUat � Homldde � DrivedOperetor � � � NO
<br />v ❑�e�n � a�re a d�rn � n�aaa�s � Pending Imeatl8adon ❑�"aer
<br />� � Noe Pregna�R, but pregna�rt wfthin a2 daye ot death � Pedestrtan 21d. WERE AUTOP3Y FlNDINGS AVAILABLE
<br />'� � Not pregnant, but preg�mnt 49 daye to 1 year betore death ���� ❑��� �� � d ��� � ourer tspeWry) TO COMPLE7E CAUSE OF DEATH4
<br />� � Unknorm H Pree�errt wttmn nre past Year ❑ YES ❑ NO
<br />E 22a. DATE OF INJURY (d1o., Day, YrJ 22b. TIME OF INJURY 22c. PLACE OF INJURY At home, farm, etreet, tactory, oftice bulldl�, eo�tructlon alte, ete. (SpecHy)
<br />$
<br />.� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />❑ res ❑ No
<br />22L LOCATION OF INJURY - STREET & NUMBER, APT.NO. CtTYlTOWN STATE ZIP CODE
<br />23a. DATE OF DEATFi (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIAf� OF DEATH
<br />.� May 14, 2011 S � �
<br />�� Z 23b. DATE SIGNED (Mo, Day, Yr.) 23c. TIME OF DEATH ��� r 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />Ma 18, 2011 09:05 AM
<br />8 � 0 9d. To the beffi of my Imowied8e. death occurted et the ti�. date and plaa $� � 2Ge. On the bssle oi anminaUon anNUr Imeatlgatlon. ln my aPlNnn death oaurtetl at
<br />e � erM tlue to the 4ause(s) atatetl. (Slgneture and TWe) . B o� the tl�. dale arttl Plaze and due to fhe causele) state0. (S16nature elM TMIe)
<br />" Rlchard Fruehling, MD ~ g �
<br />2S. DID TOBACCO USE CONTRtBUTE TO THE DEATH9 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED7 26b. WAS CONSENT GRANTED7
<br />❑ YES � NO ❑ PROBABLY � UNIWOWN ❑ YES � NO NotApplitable B28a Is NO � YES ❑ NO
<br />2. TIT AND DRESS OF C R IFIER (P YS I P OU ype or Prirtt)
<br />Richard Fruehling, MD, 2116 W Faidley #�F00, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SItiNATURE �+ _,� _ 28b. DATE FILED BY REGISTRAR (dlo., DaY� Yr.)
<br />�V May 18, 2011
<br />Exhibit "A"
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