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To be completed /verified by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Betty Ruth Butts 2. SEX ; ' ..3."6ATE, Femal6 °, . �� , '>> (Mo., Day, Yr.) J un e 1,2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Scotia, Nebraska 5a. AGE - Last Birthday (Yrs.) 76 6b. UNDER 1 YEAR 5c. UNDER 1 DAY ' 6 BATE OF BIRTH (Mo., Day, Yr.) February 2, 1937 MOS. DAYS HOURS MINE. l 7. SOCIAL SECURITY NUMBER 508 -38 -0925 8b. FACILITY -NAME (If not Institution, give street and number) 1022 West 5th Street 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1022 West 5th Street 9e. APT. NO. 8f. ZIP CODE I 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 1 Oa. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Donald Butts 11. FATHER'S -NAME (First, Middle, Last, Suffix) Raymond Murphy 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ida Fowler 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Donald Butts 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) June 3, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon 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 18. PART I. Entor 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 15 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) Metastasized Lung Cancer disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) Tobacco Use >50 Years 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 death but not resulting in the underlying cause given In PART I. Chronic Obstructive Pulmonary Disease, Cardiomyopathy 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 ❑ Omer (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 a L 11: Z 23a. DATE OF DEATH (Mo., Day, Yr.) June 1, 2013 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (M Da y, Yr .) June 3, 2013 23c. TIME OF DEATH 07:05 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3 0 9d. To the best of my knowledge, death occurred at the time, date and place S c and due to the cause(s) stated. (Signature and Title) a Steven Husen, MD 24e. On the basis of examination and /or Investig Lion, 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 26b. WAS CONSENT GRANTED? Not Applicable If 28a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print` Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 I 28a. REGISTRAR'S SIGNATURE IL `� Y A •,p �V 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) June 5, 2013 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANQ k1UMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPAR1'h OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL R` €CJ � �) " StA'NLEY. EOOPER / GIST) ll n _4TH ?Tip::: DATE OF ISSUANCE 06/05/2013 ti 0130 4 6 3 4 ASISTfT. DgpART LINCOLN, NEBRASKA HHM6IN SERVICE! STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICESA CERTIFICATE OF DEATH 'r •girt;,^," • r w 13 02434