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EXHI�3IT "�" 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 DEPARTMF,�V7" OFHFAZTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL R��'pRD�: �°` ,� '
<br />/� I �° �'•,`
<br />DATE OF ISSUANCE ��/��a�� ° U �J � �� ',�-,, ,
<br />04/26/2012 � 012 0� 5 4� S7'A�11L�1! S. COOPER '• �
<br />ASSI�ANT �TA'T.� Rr'�GI�TRAR �- � � �
<br />DEP',�4R�MEN�"�Of�t'I�AtTH ;4ND
<br />LINCOLN, NEBRASKA HUMAN PS�RVICES
<br />i b n !� . -
<br />STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICES�� �' •;;���� � p r�� ,;�", •''� ',.� 12 O'I4H7
<br />�.�R�irwH��a�rucH�n � ,�,. ••••.• ,
<br />1. DFCEDENTS•NAME (First, Mlddie, Last; SufBx) 2. SEX �'� ��'3. At� OF DEATH {1410., Day, Yr.)
<br />qgnes Rita Happ ,Female � " Apri123;2012
<br />4. C AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last Birthday b. UNDER 1 YEAR Se. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y►e•) MOS. DAYS HOURS MINS.
<br />Norace, Nebraska 88 March 29, 1924
<br />7. SOCIAL SECURIT1f NUMBER 8a. PLACE OF DEATH
<br />505-22-8305 o H SPITAL ❑ ��ueM OTHE�1' � Nursing HomeILTC � Hospiee Faetltty
<br />8b. FACIUTY•NAME (M not In,aUtutlon, give street and number) � ER/OulpaUe� � DecedeM's Home
<br />�
<br />� Tlffany Square Care Center ❑�A ❑�� (Sp��r1
<br />� 8c. C,ffY OR TOWN OF DEATH pnclude Zip Code) 8d. COUMY OF DEATH
<br />0 4rand Island 68803 Hall
<br />� ea. RESIDENCESTATE 8b. COUNTY 9c. CITY OR TOWN
<br />N�braska Howard St. Paul
<br />LL 8d. ET AND NUMBER . APT. N0. 8f. ZIP CODE 8g. INSIDE CITY UMITS
<br />602 O Street �5 68873 � res ❑ No
<br />� 10a. NWRITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Marrled 10b. NAME OF SPOUSE (First, Npddle, laet, SufWc) ItwNe, give rt�iden reme
<br />� p nnamed, n�rt separated � Wldowed ❑ Dtvoreed ❑ umc�rown Sylvanus Happ
<br />71. FATHER'S•NAME (Flrst, Mlddle, Last, Sufflx) 12. MOTHER'S-NAME (Firat, Middle, Malden Sumame)
<br />� Tt�omas Kelly Lucille Welch
<br />°� 73. EVER IN US. ARMED FORCES? Gtva dat� M service If Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ �vea, No, or unk.> No Sharon Goettsche Daughter
<br />,$ 15. METHOD OF DI9POSITION 18a. EMBALMERSIGNATURE 78b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />�? � Burlat ❑ Domadon
<br />Timeree Andreasen 1390 April 26, 2012
<br />❑ Crematlon ❑ Ernombmern 16d. CEMETERY, CREMATORY Oli OTHER LOCATION CITY I TOWN STATE
<br />❑ Removal ❑ Other (Specffy) Sacred Heart Cemetery Greeley Nebraska
<br />17a. frUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zlp Code
<br />Jacobsen-Greenway Funeral Home, 411 O Street, PO Box 112, St Paul, Nebraska 68873
<br />CA SE OF DEATH ee instructions and exam les
<br />1a pAr�T I. Enmr the chaln oT eveirte-.diseases, InJurles, or compllcationsdhet dlrecty cauead the death. 00 NOT erter tertnlnal eveMe euch as cardlac errest, ; APPROXIMATE INTERVAL
<br />teSpirerory art�t, or ve�rtricWaz flbflllatlon without sliowl� Uee etlology. DO NOT ABBtiEVIATE. Frrter onty ona eause on a Ihre. Add edAttlonal Mes ti neassary. �
<br />IMMEDIATE CAUSE: ; o�et to death
<br />IMMEDIATECAU3E(Fl�I a) Failure To Th�ive � Weeks
<br />disease or canefdon reautting �
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />s�u�� ��e ��amo�, n b)qrtertal Leg Thrombus � Weeks
<br />mry, lAading M the cat� IlsDetl
<br />on lure a. DUE TO, OR AS A CONSEQUENCE OF: : oreet to death
<br />Enterthe UNDERLYINQ CAUSE �) Atrial Fibrillatlon ; Years
<br />(dlaea� m InJury thet InNiated
<br />ure eveMe reaulUn� m deatn) DUE TO, OR AS A CONSEQUENCE OF: : o�et to death
<br />�asr d)
<br />18. P T II.OTHER SIONIFlCANT CONDITIONS-CondltJone coMMbuting to the death but not resulGng In the underlying eause given In PART 1. 18. WAS MEDICAL EXAMINER
<br />Melnutrftfon, Acute Renal Feilure, DefiydraUOn OR CORONER CONTACTEDT
<br />� ❑ YES � NO
<br />W 20. IF FEMALE: 21a. MANNER OR DEATH 27b. IF TRANSPORTATION INJURY 21c. VIIAS AN AUTOPSY PERFORMED?
<br />� � NMPBB�M�In pastyear � NaWral � Homlcide � DrivadOperator � �9 � NO
<br />v �PreBnaMattMceotdeafh �AcWdent �Pendln9lmeatleadon ❑Passen9er
<br />� NM pregnaM, but pregnent wlthin 42 daye oi Aeath g��de Could not be tlatermined � P���a" 27 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />� � Not pregnairt, but pregneirt 49 days tq 1 year before death � � � p�� �gp���yJ TO COMPLETE CAUSE OF DEATH?
<br />� ❑ ununmxn H aTeenantwuhm the �at rear ❑ YES ❑ No
<br />�' 22a. DATE OF INJURY (Mo, Day, Yr.) 22b. TIME OF INJURY 22e. PLACE OF INJURY-At home, farm, etreet, tactory, oftice bullding, constructlon ake, etc. (Speclfy)
<br />5
<br />$
<br />.� 22d. IN�IURY AT WORK7 22e. DESCRIBE HOW INJURY OCCURRED
<br />�
<br />�] vES ❑ No
<br />22f. LQ TION OF INJURY - STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) � 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />� April 23, 2012 ,� � �
<br />� 23b. DATE SIONED (Mo., Day, Yr.) 23c. TIME OF DEATH �� a r 24c. PRONOUNCED DEAD (Mo., Day, Ycy 24d. TIME PRONOUNCED DEAD
<br />� ��I ril 25, 2012 06:50 AM �
<br />$ O�'' 3d. To the beat M my Imowietl8e, death ocanretl at tha Bme, date and plaee $��� 24e. On the basle oi m�eminadon anNor ImeatlBatlOn. In my oPlnlon death xwrred at
<br />�� end due to tha eauaels) stateU. (Signature and Tkle) � O the time. date and piaee and tlue to Ure eausa(s) s�ed. (31gnaNre and TfGa)
<br />~� Travis S. Hageman, MD ~ g o
<br />25. DID„ OBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CON9ENT GRANTED?
<br />❑'YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Applicable (126a Is NO ❑ YES ❑ NO
<br />, ITL ADDRESS OF ERTIFIER (P YSIC , HYSI ASS STANT, R E S PHYSI OR C NTY A ORNEY) ype or PHnt)
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />2Ba. REGISTRAR'S SIGNATURE �- 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />April 26, 2012
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