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To be completed/verified by: FUNERAL DIRECTOR 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Marlene Ann Mead 2. SEX ' 1 " I ` Female 3. OF DEATH (Mo., Day, Yr.) •.DeoeMber 18, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Cairo, Nebraska 5a. AGE • Last Birthday (Yrs.) 73 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) January 22, 1939 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508-48 -1950 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 0 DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hail 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Wood River 9d. STREET AND NUMBER 512 Lilly Street e. APT. NO. r 9f. ZIP CODE I 68883 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 Donald D Mead 11. FATHER'S -NAME (First, Middle, Last, Suffix) Ralph Dibbem 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Evelyn C Hartwig 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or link.) No 14a. INFORMANT -NAME Doug Mead 14b. RELATIONSHIP TO DECEDENT Son 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.) December 22, 2012 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Wood River 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 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 5 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) METASTATIC ENDOMETRIAL CANCER disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: - onset to death Sequentially list conditions, if b) any, leading to the cause listed line on 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 c ' - ' - ' " ' not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 20. IF FEMALE: ® Not pregnant within past year P ❑ Pregnant time of death tme oeath ❑ 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 ❑Pen Investigation ❑ Suicide 0 Could not be determlned 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 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 b' 5 i tr. T E u El 23a. DATE OF DEATH (Mo., Day, Yr.) December 18, 2012 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.) December 19, 2012 23c. TIME OF DEATH 10:53 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 g 0 3d. To the best of my knowledge, death occurred at the time, date and place 2 o and due to the cause(s) stated. (Signature and Title) '' L 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 TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 28b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE /1� 46 _ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I December 20, 2012 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AA I- OMNI SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA,QEPARTME,VYDF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS'," DATE OF ISSUANCE 12/26/2012 STATE OF NEBRASKA STANLEY C ; r, 0, ASSISTN I � OOPER I TA ,R thI AND 'j 201301797 DE1M LINCOLN, NEBRASKA HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIO'ES' -.' F / A C A d4 .. 12 04829 • CERTIFICATE OF DEATH F r ■ ' • . • • .