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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE 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 /�/��a���"A' �tJ ' �""'U-" -
<br />06/04/2012 � 012 0 7 S 6 4 STANLEY S COOPER
<br />ASSISTANT STATE REGISTR.4R
<br />DEPARTMENT OF HEALTH AND
<br />LiNCOLN, NEBRASKA HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 12 01936
<br />CERTIFICATE OF DEATH
<br />1, DECEDENTS-NAME (Firat, Middle, Laet, Suffbc) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />Kathryn Sue Hosier Female May 22, 2012
<br />4. CITY AND STATE OR TERRITORY, OR POREIGN COUNTRY OF BIRTH Sa. AGE • Laet Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y�•) MOS. DAYS HOURS MIN3.
<br />Aurora, Nebraska 61 May 3, 1951
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH '
<br />506 �❑ InpaUeM OTHER ❑ Nuraing HomeILTC � Hosplce Facllity
<br />B. FACILITY•NAME (Ii not Ir�tltutlon, glve etreet arM number) � Ep/OutpaBeM ❑ Deeederrt's Home
<br />�
<br />° Saint Francls Medicat Center ��A ❑°�' �SP��'�
<br />�
<br />� Bc. CI7Y OR TOWN OF DEATH pnclude 21p Code) 8d. COUN7Y OF DEATH
<br />o Grand Island 688U3 Hall
<br />� 8a. RESIDENCESTATE 8b. COUNTY 8c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />� 9d. STREET AND NUMBER . APT. NO. 9f. ZIP CODE 8g. INSIDE GITY UMITS
<br />a 2925 W. Westside Street 68803 � v�s ❑ No
<br />� 10a. MARITAL STATUS AT TIME OF DEATH � Marrled ❑ Never Marrted 10b. NAME OF SPOUSE (Flrst, Middle, Lest, Sutfix) If wBe, 8�e malden name
<br />� ❑ n�arr�ed, but aeparacea ❑ Unaowed ❑ utvorced ❑ uruarown Davld E Hosier
<br />m
<br />� 11. FATHER'S•NAME (First, Middle, Laet, 3ufflx) 12. MOTHER'S-NAME (Firat, Mlddle, Nlalden Sumame)
<br />d Avery Torgerson Max(ne Huffman
<br />°' 13, EVER IN U.3. ARMED FORCESI G(ve datea of sarvlce H Y�. 14a. INFORMANT•NAME 146. RELATIONSHIP TO DECEDENT
<br />E
<br />g �r�, No, or unk.� No Davld E Hosier Spouse
<br />,� 1S', METHOD OF DISPOSITION 78a. EMBALMERSIONATURE 18b.1.iCENSE NO. 18c. DATE (Mo, Day, Yr.)
<br />�? � Burtal ❑ Do�mtlon De�ek Apfel 1240 M8y 25, 2012
<br />❑ Crematlon Q Entombment .�gd CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />p Removai ❑ Other (Specliy) Cedarview Cemetery Doniphan Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUNO ADDRESS (Street, CHy or Town, State) 17b. Zip Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See Instructions and exam les
<br />1& PART L E�rter the cheln ot eveMe��dleeasea, InJuriea, or complicatlons-that dhecUy caused tha death. DO NOT errter tertnl�ml eve�rta euch ae cardfac erresl, p AppROIOMATE INTERVAL
<br />resplratory arreat, or ve�rtrieular Hbrlllatlon �rlthout ahowing the etlotogy. DO NOT ABBREVtl1TE EMer only one eause on a tine. Atld eAtlWonal tlnee ff rreeeseary.
<br />IMMEDIATE CAUSE: ; orreet to death
<br />axMeow�causec�� a)PulmonaryEmbolus ; Immediate
<br />dlaease or conNtlon �esultl�
<br />�� d �'� DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />SOquanflalty IIaS conditio�, u b) Premature Ischemic Heart Disease ; Gradual
<br />ahy. leadln8 m We cause Iteted
<br />on Ii�re a DUE TO, OR AS A CONSEQUENCE OF: 0 o�et to death
<br />Enterthe UNDERLYINO CAUSB C �
<br />(afeeese or In)ury that �n�tlated
<br />the eveMe reauieng In death) DUE TO, OR AS A CONSEQUENCE OF: : o�et M death
<br />� d)
<br />78. PART II.OTHER SIGNIFlCANT CONDmON3-CorMittons corrtrlbuting to the death but not resulUng in the underiying cause given In PART 1. 79. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />� � YES ❑ NO
<br />W O. (F FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJU 21c. WAS AN AUTOPSY PERFORMED?
<br />� � Not preenant within Past Year � Ne�� ❑ Ho�aa. ❑ o���enoaB�sa. 0 ves � No
<br />W� Pregna�rt at dme M d�th � PeasenBer
<br />V Q � AcddeM � Pendin8 �B�on
<br />� Not pregnaM, but pregnarrt vrtthln 42 days of death g„�de cowd na be detamuned � Petl�" 21d. V1fERE AUTOPSY FlNDINGS AVAIIABLE
<br />'� Q Not pragnent, but pregnaM 49 dsya to 1 year before d�th � � � p�� (gpe���y� TO COMPLETE CAUSE OF DEATH?
<br />� � UMmown it pregna�rt wtthin the past year ❑ YES ❑ NO
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, factory, otflce butlding, consVUetlon aRe, etc. (Speetfy)
<br />�
<br />.� 22d. INJURY AT WORK? 22e. pESCWBE HOW INJURY OCCURRED
<br />F�-
<br />❑ ves ❑ No
<br />22f. LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. GTY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />S� ,s �� June 1, 2012 Approx. 11:30 AM
<br />�� r 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH �� k� 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />$„ o E< o Ma 22, 2012 12:43 PM
<br />To the best M my Imowladge, death occurteA ai the tlme. da[e and place $ 24e. On the basie af examinatlon anNor Investlgatlon, In my oPMlon tleath oxurted at
<br />�� and due to the ceuse(s) sfated. (Slgnature end Title) ��$ tlre tlme, date a�M place and due to tire catree(e) emted. (Sienature and Tttle)
<br />~ ~ g s M a r d n K l e i n, H a l l D e p u t y C o u n t y A t t o m e y
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH7 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS_CONSENT GRANTED7
<br />YES ❑ NO ❑ PROBABLY � UNKNOWN ❑ YES � NO NotApplicable Ii28a �s NO � YES ❑ NO
<br />27. E, T LE D D OF ER FIER (P I IAN, HY ICIAN I TANT, RONER IAN R N A RN ype or Print)
<br />Martln Klein, Hall Deputy County Attomey, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />28a. RE(i1STRAR'S SIGNATURE �- 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />June 1, 2012
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