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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH' ANQ VUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF' THE ORIGINAL RECORD ON FILE WITH THE NEBRASI A Dt AR Tt1 Pi T OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL. EGO DS 4 n P DATE OF ISSUANCE 06/05/2013 %STANLEY S. COOPER , 201304706 ASSISTANT,STATE ktEGIL.7 ' ' . , DF,PART NtOa ' 4AETHiAND:; LINCOLN, NEBRASKA ,HUMAN SERVICES - s STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES y, , h CERTIFICATE OF DEATH r t "c {' f? r `\ >' t*Y ,. 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Helen Dorothy Elrod 2. SE) r. ' T 4/ FemaNk � ( - 3: t`�ATE (Mo., Day, Yr.) r' June.,,; 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 89 5b. UNDER 1 YEAR 5c. UNDER 1 DAY ` 4"44YATE OF BIRTH (Mo., Day, Yr.) September 30, 1923 MOS. , DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -26 -9993 8b. FACILITY -NAME (If not Institution, give street and number) Grand Island Bickford Cottage L.L.C. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ® Other (SpecIfy)ASSISTED LIVING 8c. CITY OR TOWN OF DEATH (Include Zlp 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 3285 Woodridge Blvd APT. NO. 8f. ZIP CODE I 68801 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 11. FATHER'S -NAME (First, Middle, Last, Suffix) George Niemoth 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Elise Buckow 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14e. INFORMANT -NAME Jim Elrod 14b. RELATIONSHIP TO DECEDENT Son 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Tracey Dietz 16b. LICENSE NO. 1328 16c. DATE (Mo., Day, Yr.) June 7, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Cemetery Grand Island 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 k CAUSE OF DEATH (See instructions and examples) 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 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) Age Related Decline disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Dementia 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 1. Hypertension, Osteopenia, Vitamin D Deficiency, Hyperlipidemia, Osteoarthritis 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 0 N 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 0 Suicide Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger Pedestrian ❑ Other (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 2 W �` V g z 23a. DATE OF DEATH (Mo., Day, Yr.) June 1,2013 S o. < -J W W 0 S II' C '' S 5 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 2 3b . DATE SIGNED (Mo., Day, Yr.) J 4 2013 23c. TIME OF DEATH 07:20 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 0 ' 3d To the best of my knowledge, death occurred at the time, date and place . B g and due to the cause(s) stated. (Signature and Title) W Kimberly A. Mickels, MD 24e. On the basis of examination and/or Investig Von, In my opinion death occurred at Inc time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES, ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 128a. . REGISTRAR'S SIGNATURE /lam _wO v ff7lf(i/f/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 VUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF' THE ORIGINAL RECORD ON FILE WITH THE NEBRASI A Dt AR Tt1 Pi T OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL. EGO DS 4 n P DATE OF ISSUANCE 06/05/2013 %STANLEY S. COOPER , 201304706 ASSISTANT,STATE ktEGIL.7 ' ' . , DF,PART NtOa ' 4AETHiAND:; LINCOLN, NEBRASKA ,HUMAN SERVICES - s STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES y, , h CERTIFICATE OF DEATH r t "c {' f? r `\ >' t*Y ,.