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To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Linda Gail Green 2. SAX` ` ' Female__ ' . - 3. DATE OF DEATH (Mo., Day, Yr.) June 3, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH St. Paul, Nebraska 5a. AGE • Last Birthday (Yrs.) 65 5b. UNDER 1 YEAR 5c. UNDER 1 DAY. 6. DATE OF BIRTH (Mo., Day, Yr.) January 11, 1947 MOS. DAYS HOURS MANS. 7. SOCIAL SECURITY NUMBER 505 -56 -5202 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) St. Francis Memorial Health Center LTC ❑ 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 STREET AND NUMBER 4220 Nordic Road e. APT. NO. r e. 9f. ZIP CODE I 68803 9g. INSIDE CITY LIMITS 0 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 Floyd M Green 11. FATHER'S -NAME (First, Middle, Last, Suffix) Harold Joseph 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Marie A White 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Floyd M Green 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Chris McCoy 16b. LICENSE NO. 1191 16c. DATE (Mo., Day, Yr.) June 7, 2012 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Rose Hill Cemetery Palmer 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 15. 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 6 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) Glioblastoma Muitiforme 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 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 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 El 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 it pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suick % ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 0 N 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 t W E I "1 23a. DATE OF DEATH (Mo., Day, Yr.) June 3, 2012 i i Y < S C 8 p " s 8 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) June 4, 2012 23c. TIME OF DEATH I 09:05 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 E c and due to the cause a stated. S nature and Title 1 1 l b ) `- M Kenneth Vettel, MD z4a. On the bash 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 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, Kenneth Vettel, MD, 2116WFaidley#400, Box 26a. HAS ORGAN OR ISSUE DONATION BEEN CONSIDERED? I ❑ YES 0 NO HYSICIAN ASSISTANT CORONER'S COUNTY A 9802, Grand Isla • - ka, 68803 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES ❑ NO ORNEY) (Type or Print) 28a. REGISTRAR'S SIGNATURE di./ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) June 5, 2012 STATE OF NEBRASKA WiEN 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 DEPARTMENT OF,HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR'VITALrREGQRDSti DATE OF ISSUANCE 06/06/2012 LINCOLN, NEBRASKA 201302269 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERV.IPp§ CERTIFICATE OF DEATH -' •`,( , STANLEY S COOPER •, = ASSISTANT STATE REGISTRAR DEPAkr MENT''OF; HEALTH''AND HUMAPV SERVICE'S 12 01981