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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Merle William Sundermeier 2, SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) June 5, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Doniphan, Nebraska 5a. AGE - Last Birthday (Yrs.) 86 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) March 6, 1926 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -44 -1770 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Primrose Retirement of Grand Island ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ® Other (SpecIfyIASSISTED LIVING 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 3990 W. Capital Ave. 9e. APT. NO. 123 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS M 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 Doris Brehm 11. FATHER'S -NAME (First, Middle, Last, Suffix) William H Sundermeier 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Frieda Lena Obermeier 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Doris Sundermeier 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Kevin Wood 16b. LICENSE NO. 1325 16c. DATE (Mo., Day, Yr.) June 9, 2012 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Phillips Cemetery Phillips Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livingston - Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 17b. Zip Code 68803 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 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 Hours respiratory arrest, or ventricular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially 8st conditions, if b) Pulmonary Fibrosis Months any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Entcrthc UNDERLYING CAUSE c) Waldenstroms Macroglobulinemia Years (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART H. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ 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 ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could 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 .1 W m F E 0 21 z 23a. DATE OF DEATH (Mo., Day, Yr.) June5,2012 To be completed by CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) J u n e 28, 2012 23c. TIME OF DEATH I 07:30 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 u O 3d. To the best of my knowledge, death occurred at the time, date and place E and due to the cause(s) stated. (Signature and Title) M Travis S. Hageman, MD 24e. On the basis of examination andior 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 EI 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, Travis S. Hageman, MD, 729 North Custer Avenue, HYSICiAN ASSISTANT, CORONER'S OR COUNTY AYTORNEY) (Type or Print) Grand Island, Nebraska, 68803 I 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I July 2, 2012 DATE OF ISSUANCE 07/05/2012 LINCOLN, NEBRASKA STATE STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ALWal i 14N,SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR I P R EINT F PIEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY CR VITA m 201303641 ST $ c DEPARTMENT EN ib HUMAN +SERVICES OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES -- ' CERTIFICATE OF DEATH 12 02334