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I STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANl� H(1M�dAl'S€RVIEES,, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WI7'H THE NEBRASKA�>D P,A,I��"M���;OP HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSI7'ORY FOR VFFAL,I��ORDS •..`" �
<br />� i
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<br />DATE OF ISSUANCE , [,
<br />• r� �.;, • �C.! � �.�"""� �',,_
<br />� V � � � a7 � �7 � STAN�E� S. QPER, r '; ;, r ;
<br />04/26/2012 a5s�t��Q��'���ifi� � �r.�rR4R� �'
<br />DEP�I��'Nl�N O�'`�'IFAL.TFCAND � ,
<br />LINCOLN, NEBRASKA HUMAI�aSfRV�CES ` .',f
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC�S ,, �' ��/i '? P,' ;� �',�� �,, = � 2 O� 359
<br />[`FRTIRICATF AF 11FOTN r '�'l � • • • � ,
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<br />7. DECEDENTS�NAME (First, Mtddle, Last, Suftbc) 2. SEX _.��. �3: DATE OF'DEATH (Mo., Day, Yr.)
<br />Shirlee Jean Dibbern Female Apr11 14, 2012
<br />4. CITY AND 3TATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AOE • Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y�•) M09. DiAYS HOURS hlONS.
<br />Scribner, Nebraska 81 ' June 28, 1930
<br />7. SOCULL SECURITY NUMBER 8a. PLACE OF DEATH
<br />50&30-3012 OSH PRAL � InpatleM OTHER � Nwaing HomeILTC � Hosplce Facltity
<br />8b. FACILITY•NAME (H not Iretitution, give etreet and number) � ERIOutpatlerR ❑ DeeedeM's Home
<br />�
<br />� Westem HaII County Good Samaritan Center ❑ DOA ❑ oemr (speatyl
<br />� 8c. CITY OR TOWN OF DEATH (trrclude Zlp Code) 8d. COUNTY OF DEATH
<br />o Wood River 68883 Wall
<br />� 8a. RESIDENCE-STATE 9b. COUNTY 9c. CI7Y OR TOWN
<br />Nebraska Hall Grand Island
<br />LL 8d. STREET AND NUMBER : APT. NO. 8f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />;; 5688 N. Webb Road 68803 ❑ res � No
<br />a 10a. MARITAI STATUS AT TIME OF DEATH � Marrled ❑ Never Married 10b. NAME OF SPOUSE (Flret, Mlddle, Last, Suffiz) If wtfe, glve malden name
<br />� '
<br />� ❑ nnamaa, n�csa�cea ❑ v►naowea ❑ oworced p u��rown Keith Dibbem
<br />� 11. FATHER'S•NAME (Flrat, Mlddle, Last, SuHiu) 12. MOTHER'S-NAME (Flrst, Middle, Malden Surname)
<br />� Leo H Weiman Florence A Hankins
<br />°� 13. EVER IN U.S. ARMED FORCES4 Give dates M servlce H Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />$ (Y�, No, or unk.) No Keith Dlbbem Spouse
<br />, 15. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. UCENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />�? � Burlal ❑ DonaUon
<br />Tracey Dietr 1328 April 20, 2012
<br />❑ CremaGon � EnMmbment 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removab ❑ Other (Speclty) gurwick Cemetery I Cairo Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, CI or Town, Sfate) 17b. Zlp Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See Instructlons and exam les
<br />18. PART I. EMer the chafn oi eveMa-�dl�s, InJurlee, ar tomplicatlon�that tlirecUy cauaetl the death. DO NOT eMer terminal eve�rte such as cardlac arreet, ; APPROXIMATE INTERVAL
<br />respiratory ertest, or veMricular flbriUeGon wkhout showinp the etlotopy. DO NOT ABBREVIATE. E�rter only one cause an a qne. Adtl addltlonal Wree H�ry.
<br />IMMEDUITE CAUSE: ; onset to death
<br />uxeeeoure cnuse � a) Myelofibrosis 6 6 Months
<br />dlaease or canditlon reaulUng ��,
<br />� d �'� DUE TO, OR AS A CONSEQUENCE OF: 0 onaet to death
<br />8equeMla�y n� candHiona. R b)
<br />anY, IeaAing to the cause Ilated
<br />on I�ne e. DUE TO, OR AS A CONSEQUENCE OF: � oriset to death
<br />Emerthe UNDERLYINO CAUSE �) ��
<br />(dlaeaee or InJury that InitlaOed �' '
<br />Ne eveMe reauldnp In tleath) DUE TO, OR AS A GONSEQUENCE OF: � onset to death
<br />� d)
<br />18. PART II.OTHER SIGNIFlCANT CONDITIONS-CorMfUo� contributing to the death but not resulUng In the umleriytng cauae given In PART I. 1B. WAS MEDICAL EXA(YDNER
<br />OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />W 0. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WI6S AN AUTOPSY PERFORMEDI
<br />�
<br />� � Not Pre6naMwffhM P�Ye� � NaWral � Homldde � DNveKbPe��r � YE9 � NO
<br />W Prepnairt at tlme oi deafh �� Passanper
<br />V � AcdtleM � Pemlinp Invastlpatlon
<br />a � NM prepnant, but pregnent within 42 daye ot death � Pedeapian 21d. WERE AUTOPSY FWDINGS AVAILABIE
<br />� Suldde � Coulu not be determlired TO COMPLETE CAUSE OF DEATH?
<br />� Not Pre9oa�rt. but pee9nant 49 days to 1 Yeer beTare death � Other (BP�HN)
<br />� � Unknown If pregnamwithln the paetyear �� � N �
<br />E 2?s. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, sVeet, tactory, office bulldl�, correWctlon sRe, etc. (SpecHy)
<br />s
<br />.� ?2d. INJURY AT WORK7 22e. DESCRIBE HOW INJURY OCCURRED
<br />F�-
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) ` 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />S� April 14, 2012 �� r
<br />� � 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ���} 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />i A rii 17, 2012 02:30 AM <
<br />� e� 0 9d. To the best of my Imowledge, death accurred et Ure Ume, date and plaea �� yqe, pn the I�sis oi exeminadon and/or InveaGBadon, ln my opinion death oaurted at
<br />�� end due to the cause�e) etaDetl. (Signature and TMIe) ��� ene nme, tlate and plece end due ro the eause(e) etated. (Slgnawre and Tkle)
<br />Gary SettJe, MD g o
<br />2S. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED7
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO NotAppllcable H28a Is NO ❑ YES ❑ NO
<br />2. NAME, ITL D AD RE OF ERTI ER P Y I Y 1 1 TANT, NER N (Type or rn
<br />Gary Settja, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REOISTRAR'S SIGNATURE �- `-_- 28b. DATE FlLED BY REGISTRAR (Mo., Day, Y�.)
<br />�QIVV
<br />Aprll 17, 2012
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