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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Georgia Ann Strotman 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) January 6, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Exeter, Nebraska 5a. AGE - Last Birthday (Yrs.) 90 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) December 26, 1922 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -18 -8119 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) 2910 West 13th Street ❑ ER/Outpatient Q 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 9d. STREET AND NUMBER 2910 West 13th Street 19e. APT. NO. 9t. ZIP CODE I 68803 9g. INSIDE CITY LIMITS I ® 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 Gene Strotman 11. FATHER'S -NAME (First, Middle, Last, Suffix) George Becker 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Anna Franzen 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Gene Strotman 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Mike McQuiston 16b. LICENSE NO. 1129 16c. DATE (Mo., Day, Yr.) January 9, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Aurora Catholic Cemetery Aurora Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Higby McQuiston Mortuary, Inc., 1404 L Street, PO Box 204, Aurora, Nebraska 17b. Zip Code 68818 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 18. PART 1. Enter the chain of events - diseases, Injuries, or complications4hat 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 H necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Heart Arrhythmia disease or condition resulting In ) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) any, leading to the cause listed lure 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 drat` but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO IF FEMALE: ] Not pregnant within past year ] Pregnant at time of death ] Not pregnant, but pregnant within 42 days of death 0 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 El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) AINO A3NNOJ LV A1 Nfl03 NVI3ISANd S.i13NO21O3 Aq pe{e{duoa eq 01. 24a. DATE SIGNED (Mo., Day, Yr.) January 8, 2013 24b. TIME OF DEATH Approx. 01:00 AM 23b. DATE SIGNED (Mo., Day, Yr.) 123c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) January 6, 2013 24d. TIME PRONOUNCED DEAD 07:25 AM 9d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 2M. On the basis 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 TUN) Dave Medlin, Hall Deputy County Attomey 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 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Dave Medlin, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 28a. REGISTRAR'S SIGNATURE /�� `,i _ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I January 10, 2013 DATE OF ISSUANCE 01/15/2013 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL;T H Ahil6)1A� ERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT Qe HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. STANLEY *COOPER ASSISTicV r FiEpxSfRAR 20130 4'71 DEPARTMENT OF HEALTH, AND LINCOLN, NEBRASKA HUMAN $1ERVICE$. f STATE OF NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVIoES' CERTIFICATE OF DEATH `'