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To be completed/verified by: FUNERAL DIRECTOR 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Joan Elaine Spiehs 2. SEX Female t 3; DATE',OF DEaiTMN(Mo., Day, Yr.) August 6;2011 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE • Last Birthday (Yrs.) 88 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) April 5, 1923 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -22 -8369 8b. FACILITY -NAME (If not Institution, give street and number) Tiffany Square Care Center 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home 0 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 3119 West Faidley Avenue 9e. APT. NO. 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) If wife, give maiden name Harold L Spiehs 11. FATHER'S -NAME (First, Middle, Last, Suffix) Chris Bruhn 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mary Joehnck 13. EVER IN U.S. ARMED FORCES'? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Richard Spiehs 14b. RELATIONSHIP TO DECEDENT Nephew 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Chris McCoy 16b. LICENSE NO. 1191 16c. DATE (Mo., Day, Yr.) August 10, 2011 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Memorial Park 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 DEATHJSee instructions and examples) To be completed by: CERTIFIER I 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 3 Months 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) End Stage Systolic Congestive Heart Failure disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) Diffuse Vascular Disease any, leading to the cause listed on line 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 11. 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? 0 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 ❑ Acc ❑ Pen pion ❑ Suicide ❑ Could 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 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 E' W 9 F 2 IX E 2' 23a. DATE OF DEATH (Mo., Day, Yr.) August 6, 2011 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) August 8, 2011 23c. TIME OF DEATH I 09:15 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 0 3d. To the best of my knowledge, death occurred at the time, date and place 2 � c and due to the cause(s) stated. (Signature and Title) 2 Richard Fruehling, 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 ❑ YES ISSUE DONATION BEEN CONSIDERED? fl • I 26b. WAS CONSENT GRANTED? ' Not Applicable If 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, HYSICIAN ASSISTANT , CoRown PHYSICIAN OR COUNTY A P Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, - Nebraska, 68803 ORNEY) (Type or Print) 28a. REGISTRAR'S SIGNATURE A- I 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I August 9, 2011 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AVO 1dWMA11 ERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA"D Pgl+11 4 NT ()F�HE,4LTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR 31,11 CORDS, � S FALEY `. COOPER 201301041 ASSI7'AN E c SrRA�{ DEpA 1'{v1E t ALTHF AWD LINCOLN, NEBRASKA HUMAN FERVIC, r ' STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE k� ' `•' * ; 11 02628 DATE OF ISSUANCE 08/10/2011 CERTIFICATE OF DEATH