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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA Q EA riat P OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL-REGQ .,., r -) 4 DATE OF ISSUANCE 12/31/2012 LINCOLN, NEBRASKA 2 01300357 STANgY S. COOPER ASSISTANT STATE DEPPRTMEI L7H AN l HUMAN S STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICO'. A . r 2 04915 CERTIFICATE OF DEATH ' �f }�c,,�`.- * 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Caletta Maxine Oakley 2. SEX Female ' 3: DATE OF D A *H.(Mo., Day, Yr.) '!_December2D, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Stockham, Nebraska 5a. AGE - Last Birthday (Yrs.) 92 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE crp BIRTH (Mo., Day, Yr.) February 5, 1920 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 561 -18 -3621 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Wedgewood Care Center ❑ 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 Grand Island 9d. STREET AND NUMBER 800 Stoeger Drive APT. NO. I 9f. ZIP CODE 68803 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) It wife, give maiden name Ralph Fredrick Oakley 11. FATHER'S -NAME (First, Middle, Last, Suffix) Raynard Bird 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Cecil Smith 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Sandra Parr 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Laurie D. Sheffield 1613. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) December 29, 2012 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE Soulville Cemetery Boelus Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 1713. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain 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 Years 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) Cardiopulmonary Arrest disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) Aortic Stenosis any, leading to the cause listed on line a. onset to death Years DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Mitral Regurgitation (disease or injury that initiated onset to death Years the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 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 20. IF FEMALE: ❑ Not pregnant within past year ❑ 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 0 Pending Investigation ❑ suicide ❑Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE W I } I u Z 23a. DATE OF DEATH (Mo., Day, Yr.) December 20, 2012 d i i E E a. < .!-.1 8 W z 0 2 = p ~ 0 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) Decem 26, 2012 23c. TIME OF DEATH 01:05 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3d. To the best of my knowledge, death occurred at the time, date and place 2 a and due to the cause(s) stated. (Signature and Title) ` 2 Kenneth Vettel, MD 24e. On the basis of examination and/or investig tion, 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? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Kenneth Vettel, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 1 28a REGISTRAR'S SIGNATURE (� 2813. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 27, 2012 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA Q EA riat P OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL-REGQ .,., r -) 4 DATE OF ISSUANCE 12/31/2012 LINCOLN, NEBRASKA 2 01300357 STANgY S. COOPER ASSISTANT STATE DEPPRTMEI L7H AN l HUMAN S STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICO'. A . r 2 04915 CERTIFICATE OF DEATH ' �f }�c,,�`.- *