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� STATE OF NEBRASKA - <br />� ` <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 <br />O <br />� <br />�a <br />e <br />� <br />W <br />Z <br />� <br />LL <br />a�' <br />� <br />� <br />� <br />a <br />E <br />� <br />.� <br />� <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 ' <br />-- - - , _ <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, <br />m <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 <br />P <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) <br />� <br />W <br />LL <br />K <br />W <br />t� <br />a <br />� <br />a <br />E <br />8 <br />.� <br />H <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 <br />B� <br />� ��� 24c. PRONOUNCEO DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DPAI <br />��o <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) <br />r�� <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 <br />