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To be completed/verified by: FUNERAL DIRECTOR 1. DECEDENTS-NAME (First, Middle, Last, Suffix) Karen Kay Hostetler 2. SEX Female 3. DATEOF DEATH (Mo., Day, Yr.) February 13, 2011 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Mason City, Nebraska 5a. AGE - Last Birthday (Yrs.) 67 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) June 8, 1943 MOS. DAYS HOURS - MINS. 7. SOCIAL SECURITY NUMBER 508 -64 -4350 8b. FACILITY -NAME (If not Institution, give street and number) Westem Hall County Good Samaritan Center 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home /LTC ❑ Hospice Facility j] ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Wood River 68883 8d. COUNTY OF DEATH Hall 9a. RESIDENCESTATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Cairo 9d. STREET AND NUMBER 11373 W. Whitecloud Road 9e. APT. NO. 9f. ZIP CODE 68824 9g. INSIDE CITY LIMITS I ❑ YES 0j 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 Ervin Monroe Hostetler 11. FATHER'S -NAME (First, Middle, Last, Suffix) Wayne Evans 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Maude Esther Lloyd 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Eric Hostetler 14b. RELATIONSHIP TO DECEDENT Son 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.) February 16, 2011 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Mennonite Cemetery Wood River 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 18. PART 1. 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 Immediate respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Inc. f Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Cardiac Arrest disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) Huntington's Chorea Years any, leading to the cause listed on Inc I a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (disease or Injury that initiated 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 0 N 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 49 days to 1 year before death ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ 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 .2'W 1 E y E LI z 23a. DATE OF DEATH (Mo., Day, Yr.) February 13,2011 �g I E , t o. a = N 8 w z O 8 z p ~ s 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) February 15, 2011 23c. TIME OF DEATH I 10:00 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD $ Q 0 3d. To the best of my knowledge, death occurred at the time, date and place S c and due to the cause(s) stated. (Signature and Title) 2 Gary Settje, 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 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Gary Settje, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 1 28a. REGISTRAR'S SIGNATURE /l+ A � 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I February 15, 2011 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH. 4AD kitIMA,10.9EftVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA,6E7 MEVe pnilEALTFI AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR- VITAL,REC • . '.. 1 DATE OF ISSUANCE 02/17/201 1 LINCOLN, NEB STANLEY 'C©OP i ; {" er r° ASSISTAN $7 T ' E&ISTl AP • ' DEpAaj7MENT OF HEALTH AN .?) NEBRASKA HEJM' SEpVI S': - STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES;` , , "" 11 00466 CERTIFICATE OF DEATH °, ; J (;; 201300457