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To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Gale Jean Ochsner 2. SEX - t ,/ i Female , ' : fd, l A+E,OF DEATH (Mo., Day, Yr.) N .. ' No ye tithe r 30, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 71 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) February 23, 1941 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -46 -0770 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Alda 9d. STREET AND NUMBER 5 Venus � e. APT. NO. I 9f. ZIP CODE I 68810 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name Ronald D Ochsner 11. FATHER'S -NAME (First, Middle, Last, Suffix) Dale Findley 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Lora McKenzie 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Ronald D Ochsner 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Tracey Dietz 16b. LICENSE NO. 1328 16c. DATE (Mo., Day, Yr.) December 4, 2012 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER I 18. PART 1. Enter the yhain of events-diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death Immediate respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Sudden Cardiac Death disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) Ventricular Tachycardia Immediate any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE C) Systolic/Diastolic Heart Failure Weeks (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d)Community Acquired Pneumonia /Sepsis Weeks 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 0. IF FEMALE: ® Not pregnant within past year 0 Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ID Pending investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE b' 6 t Z 23a. DATE OF DEATH (Mo., Day, Yr.) November 30, 2012 ��< i E k E - < Z t' O 8 5 z p ~ 0 o 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) December 6, 2012 23c. TIME OF DEATH 09:10 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 u < 0 3d. To the best of my knowledge, death occurred at the time, date and place B u and due to the cause(s) stated. (Signature and Title) o fr g Michael A. Donner, MD 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN I26a. HAS ORGAN OR ❑ YES ISSUE DONATION BEEN CONSIDERED? 0 NO 26b. WAS CONSENT GRANTED? Not Applicable It 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Michael A. Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska 68803 28a. REGISTRAR'S SIGNATURE O Ili 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I December 6, 2012 DATE OF ISSUANCE 12/11/2012 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH QNl3n ft5zIT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASII HEAtIH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR - I_T1Li RECORDS.,'" ..... +�!- •,,, 201210731 SI•�4NIfl S. COOPER I .S. ISTA 1 S 4T r -, C ,EPARTM 0� H AAIL5 ,;" LINCOLN, NEBRASKA FltlglN. SERVICES;, - l , >; ,, STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES'•..(` a n ri S\ • � � ' J 12 04619 CERTIFICATE OF DEATH ` tr -' • - • • • • t ;