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To be completed/verified by: FUNERAL DIRECTOR <br />1 <br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix) <br />Margaret Ella Hessel <br />2. SEX ' 1 '• a <br />Female \ * <br />13i DfTbOF DEATH -(Mo., Day, Yr.) <br />i ,Auguat-30, 2012 <br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH <br />Richland, Nebraska <br />5a. AGE • Last Birthday <br />(Yrs.) <br />91 <br />5b. UNDER 1 YEAR <br />5c. UNDER 1 DAY <br />6. DATA OF BIRTH (Mo., Day, Yr.) <br />April 7, 1921 <br />MOS. <br />I <br />DAYS <br />HOURS <br />MINS. <br />7. SOCIAL SECURITY NUMBER <br />506 -18 -6134 <br />8b. FACILITY -NAME (If not Institution, give street and number) <br />Heritage Living Center <br />8a. PLACE OF DEATH <br />HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility <br />❑ ER/Outpatient ❑ Decedent's Home <br />❑ DOA ❑ Other (Specify) <br />8c. CITY OR TOWN OF DEATH (Include Zip Code) <br />St. Paul 68873 <br />8d. COUNTY OF DEATH <br />Howard <br />9a. RESIDENCE -STATE <br />Nebraska <br />9b. COUNTY <br />Howard <br />9c. CITY OR TOWN <br />St. Paul <br />STREET AND NUMBER <br />920 Jackson Street <br />e. APT. NO. <br />r e. <br />I 8f. ZIP CODE <br />68873 <br />9g. INSIDE CITY LIMITS <br />® YES ❑ NO <br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married <br />❑ Married, but separated ® Widowed ❑ Divorced ❑ Unknown <br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name <br />Raymond Hessel <br />11. FATHER'S•NAME (First, Middle, Last, Suffix) <br />Herman D Schmidt <br />12. MOTHER'S -NAME (First, Middle, Maiden Surname) <br />Reminnie D Michaelson <br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. <br />(Yes, No, or Unk.) No <br />14a. INFORMANT -NAME <br />Robert Hessel <br />1413. RELATIONSHIP TO DECEDENT <br />Son <br />15. METHOD OF DISPOSITION <br />❑ Burial ❑ Donation <br />® Cremation 0 Entombment <br />❑ Removal ❑ Other (Specify) <br />16a. EMBALMER - SIGNATURE <br />Not Embalmed <br />16b. LICENSE NO. <br />16c. DATE (Mo., Day, Yr.) <br />August 30, 2012 <br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE <br />Central Nebraska Cremation Services Gibbon Nebraska <br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) <br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska <br />17b. Zip Code <br />68801 <br />1 <br />CAUSE OF DEATH (See instructions and examples) <br />To be completed by: CERTIFIER <br />18. PART I. Enter the chain of events- -diseases, Injuries, or complicatlonsdhat directly caused the death. DO NOT enter terminal events such as cardiac arrest, <br />APPROXIMATE INTERVAL <br />onset to death <br />6 Months <br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. <br />IMMEDIATE CAUSE: <br />IMMEDIATE CAUSE (Final a) Failure To Thrive <br />disease or condition resufiing <br />In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death <br />Sequentially list conditions, If b) DM Type 2 Years <br />any, leading to the cause listed <br />line <br />on a. DUE TO, OR AS A CONSEQUENCE OF: onset to death <br />Enter the UNDERLYING CAUSE c) Coronary Artery Disease Years <br />(disease or Injury that initiated <br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death <br />LAST d) Hypothyroidism Years <br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the c . . . . 4 resulting in the underlying cause given in PART I. <br />Chronic Back Pain With Spinal Stenosis, COPD, <br />19. WAS MEDICAL EXAMINER <br />OR CORONER CONTACTED? <br />❑ YES El NO <br />,20. IF FEMALE: <br />❑ Not pregnant within past year <br />0 Pregnant at time of death <br />❑ Not pregnant, but pregnant within 42 days of death <br />❑ Not pregnant, but pregnant 43 days to 1 year before death <br />❑ Unknown if pregnant within the past year <br />21a. MANNER OF DEATH <br />® Natural ❑ Homicide <br />❑ Accident 0 PenInvestigation <br />❑ Suicide ❑ Could nmined <br />21b. IF TRANSPORTATION INJURY <br />❑ Driver /Operator <br />❑ Passenger <br />❑ Pedestrian <br />❑ Other (Specify) <br />21c. WAS AN AUTOPSY PERFORMED? <br />❑ YES 0 N <br />21d. WERE AUTOPSY FINDINGS AVAILABLE <br />TO COMPLETE CAUSE OF DEATH? <br />❑ YES ❑ NO <br />construction site, etc. (Specify) <br />22a. DATE OF INJURY (Mo., Day, Yr.) <br />22b. TIME OF INJURY <br />22c. PLACE OF INJURY •At home, <br />farm, street, factory, office building, <br />22d. INJURY AT WORK? <br />❑ YES ❑ NO <br />22e. DESCRIBE HOW INJURY OCCURRED <br />22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE <br />% <br />I i <br />° z <br />23a. DATE OF DEATH (Mo., Day, Yr.) <br />August 30, 2012 <br />To be completed by <br />CORONER'S PHYSICIAN <br />or COUNTY ATTORNEY <br />ONLY <br />24a. DATE SIGNED (Mo., Day, Yr.) <br />24b. TIME OF DEATH <br />23b. DATE SIGNED (Mo., Day, Yr.) <br />August 30, 2012 <br />23c. TIME OF DEATH <br />02:30 AM <br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) <br />24d. TIME PRONOUNCED DEAD <br />6 < 0 3d. To the best of my knowledge, death occurred at the time, date and place <br />• a and due to the cause(a) stated. (Signature and Title) <br />1-. a Angela Brennan, MD <br />24e. On the basis of examination and /or investigation, in my opinion death occurred at <br />the time, date and place and due to the cause(s) stated. (Signature and Title) <br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO <br />26b. WAS CONSENT GRANTED? <br />Not Applicable If 26a is NO ❑ YES ❑ NO <br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print <br />Angela Brennan, MD, 1113 Sherman St, PO Box 406, St. Paul, Nebraska, 68873 <br />1 28a. REGISTRAR'S SIGNATURE /lr <br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I <br />August 30, 2012 <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AN ijUIN. <br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA °DEPARTM <br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL (2EtbR'L� <br />DATE OF ISSUANCE <br />11/13/2012 <br />LINCOLN, NEB <br />STATE OF NEBRASKA <br />201302245 <br />ST,'ANLEY s. COOPER <br />ASSIST ANT 5'iT <br />N SERVICES, IT CERTIFIES <br />4F HEALTH AND <br />TRA !Via <br />r' <br />DEPARFMEN� <br />NEBRASKA HU(1AN. ERVICES <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER *¢E4, ^i/� �� t �° • • 1 r F <br />CERTIFICATE OF DEATH # ; c <br />:12 03167 <br />