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� STATE OF NEBRASKA -
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<br />Wl?EN THIS COPY�ARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAl1f"SERV,ICE'�; 7T CERTIFZES
<br />THE BELOW TO � A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPA�9"�EN`F'�, J�EAl.TH AND
<br />H�IMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL,7��E��a �" -�� „"'� t ,
<br />_� � F ,,, 9�: , ,,
<br />DATE OF ISSUANCE ,, ��r^ ��', � � , ,
<br />�����a��%� :� - ,
<br />04/05/2012 � STANtEY`s; �OOP�tz, , �' �'. '
<br />ASS.fSTA`l�l'T ST TE RE�ISFRRR " �
<br />2�D 1���i��� f �4 �� ,�� ,� .
<br />DEPAR7"M. �NT C��A H�'�NP �� � °
<br />LINCOLN, NEBRASKA HUMAN,�S�RV1�C �
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES�4 ��` ,�+� _ c r�''Z Q 1191
<br />CERTIFICATE OF DEATH ';. �'�!`��� F�4`�`°` f;
<br />*
<br />pECEDENTS-NAME (Firat, Middle, Last, Suffbc)
<br />June Marle Grlebel
<br />ITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />i. �OCWL SECURITY NUMBER
<br />505-92-7026
<br />Bb., FACILITY•NAME (H rrot 6qtidrtlon, give atreet ami
<br />2926 Idaho Avenue
<br />Bc., CI'fY OR TOYVN OF DEATH pneWde Zip Code)
<br />Grand Island 68803
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<br />Nebraska
<br />Hall
<br />Grand Island
<br />SIX `' ; 3. DATe OF
<br />Female It % ° ' �al�cfi 1
<br />�Y�
<br />� � � June 10, 1960
<br />OTHER ❑ Nursing HomeILTC � Hoaplce Faellity
<br />� DecedeM's Home '
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<br />❑ Other (SP�ff
<br />COUNTY OF DEATH
<br />Hall
<br />. STREET AND NUMBER . APT. NO. 9t ZIP CODE 9g. INSIDE CITY LIMff,
<br />9261daho Avenue 68803 � res ❑ No
<br />a. MARRAL STATUS AT TIME OF DEATH � Marrted ❑ Never Married 10b. NAME OF 8POUSE (First, Middle, Last, Suffix) IT wHe, give maiden reme
<br />rwamea butseparated ❑ Widowed ❑ oroorced ❑ un�cnown Alan Grlebel
<br />. FATHER'&NAME (First, Middle, Last, Suffbc) 12. MOTHER'&NAME (Firaf, Middle, Maiden Surreme)
<br />Henry John Fischer Agnes Georgia Lukesh
<br />: EVER IN US. ARMED FORCES7 Ghe dates o} servica HY�. 14a. INFORMANT
<br />(iree, No, or unk.� No Alan Griebel
<br />..METHOD OF OISPOSITION 18a. EMBALMERSIGNATURE 78b. UCENSE NO.
<br />� Bw�al ❑ Domauon Derek Apfel 1240
<br />Q Crematlon � ErrtombmerR 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Q Removal ❑ Other (SpecHy)
<br />Douglas Grove Cemetery Comstock
<br />. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Cily or Town, Sfate)
<br />14pfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />& pART L Pster dre ehaln oOeveMa-�seaeea, I�Judee, or wmplleatlonedhat tllrediy eaused the tleath. DO NOT errter te�minal eve� auch ae eartlfae arrert,
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<br />resplraWN ertest, or vaMrtwiar flOrOtatlon wkhout showfnp Ne etiolopy. DO NOT ABBREVWTE E�rter onry mre wuee on a Wre. AAA atlditlormt Ibrea fl iro�y.
<br />IMMEDIATE CAUSE:
<br />��owre ca,se � a) Colon Cancer, Metastatic
<br />tlisaaee or condition reaultinp
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />s�que�ry nst conareom, rc b)
<br />aey. leading to the eause tlated
<br />on ii� a DUE TO, OR AS A CONSEQUENCE OF:
<br />encerme uNO�nNO cause °)
<br />(disaaee orinlurythatinftlatetl �
<br />th� eveme reaultlnp in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST �
<br />STATE
<br />B.' PART II.OTHER SIGNIFlCANT CONDITIONS�CO�ultttorre co�uting W the death but rrot r�ulUng In the urnieriyh�g cause gtven In PART I. 18. WAS MEDICAL EXAMINER
<br />OR CaRONER CONTACTED?
<br />❑ YES � NO
<br />). IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />� NM PreB�twtthln P�Y�+ � NaWrat � HaMdde ❑ 0�'B�f�P��� � YES � NO
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<br />� Prepnan! et tlme M tleath � � � P�nBer
<br />Accida�U PentllnB ImestlBetlon
<br />� NM p�eg�M, but pregnant withln 42 days of tleatl� � PedesVian 21d. WERE AUTOPSY FlNDINOS AVAILA
<br />[] Not prepnaM, but pregnant 43 tlaya to 1 year befoie death ❑ su�a�de � CoWtl nM be delemU�retl ��r,s�� TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />Q Unknown if pregneM withln the past year
<br />2a. DATE OF INJURY (Mo„ Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, atreet, factory, oftlee buiidi�, eo�rentructlon site, etc. (Speciry)
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<br />d. INJURY AT WORK? I22e. DESCRIBE HOW INJURY OCCURRED
<br />❑ YES ❑ NO
<br />f. LOCATION OF INJURY - STREEf & NUMBER, APT.NO. CITYITOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />� March 12, 2012
<br />� 23b. DATE SI�NED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Z A ril 3, 2012 05:10 PM
<br />� � 3d. To tlre best ot my Imonted9e. daeth xwrred et the tlme. date and place
<br />end due to the cause(s) sfated. (SlgnaWre end Tkle)
<br />Ryan Ramaekers, MD
<br />14b. RELATIONSHIP TO DECEDENT
<br />1 Bc. DATE (Mo., Day, Yr.)
<br />March 16, 2012
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />APPROXIMATEINTERVAL
<br />o�et to death
<br />1 Year
<br />oreet to death
<br />onset to death
<br />ZIP CODE
<br />�� 24a. DATE SIGNED (Mo„ Day, Yr.) 24b. TIME OF DEATH
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<br />� ��� 24c. PRONOUNCEO DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DPAI
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<br />8 24e. On tha basia of mcaminAtlon anNa inveetlBetlon, In my opinlan tleath occurted et
<br />o&$ the tlme, date and pla� a�M due to tlre cauae(e) eta�d. (Slpnature and Tlde)
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<br />YES � NO �J PROBABLY �J UNIWOWN � �J YES � NO
<br />� TIT E AND ADDRE CERTI IER �f 1 , Y 1 N ISTANT, �1��
<br />�n Ramaekers, MD, 2116 W. Faidley Avenue, Grand Island, Nebraska,
<br />GISTRAR'S SIGNATURE�� �-
<br />NotAppticable 1i28a Is NO ❑ YES �J NO
<br />28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />April 4, 2012
<br />APR � 0 Z012
<br />51 � �
<br />i. PLACE OF �EATH
<br />HOSPRAL � inpatleM
<br />❑ ERIOutpatlerR
<br />❑ DOA
<br />AOE - Laet BtRhd�y b. UNDER 1 YEAR Sc. UNC
<br />(Y►e•) MOS. DAYS HOURS
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