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To be completedtverifled by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Laura Melissa Ahrens 2. SEX - Female 1.'15ATE OF DEATH (Mo., Day, Yr.) August 23, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Loup County, Nebraska 5a. AGE • Last Birthday (Yrs.) 96 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) June 3, 1917 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -09 -4915 8a. PLACE OF DEATH ..... HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LT( ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Tiffany Square Care Center ❑ 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 I 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 3119 West Faidley Avenue e. APT. NO. r 9f. ZIP CODE 68803 9g. INSIDE CITY LIMBS ® 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 Walter Ahrens 11. FATHER'S -NAME (First, Middle, Last, Suffix) Guy Hyde 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Elva Howard 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Gail Bond 141t. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Tracey Dietz 16b. LICENSE NO. 1328 16c. DATE (Mo., Day, Yr.) August 29, 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 CAUSE OF DEATH (See instructions and examples) I 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 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) Failure To Thrive disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Osteoporotic Compression Fracture Chronic 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. Atrial Fibrillation, hypertension, hypothyroid, 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES N 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 Coultl not be determined ❑ ❑ 21b. IF TRANSPORTATION INJURY ❑ DrlverlOperator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® 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 ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE a'' w i z , I u i 23a. DATE OF DEATH (Mo., Day, Yr.) August 23, 2013 .t g 1 I _ ° Y g 6 a i N w O 2 z C ~ o 0 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo, Day, Yr.) August 29, 2013 23c. TIME OF DEATH I 03:35 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD q 0 9d. To the best of my knowledge, death occurred at the time, date and place 2 o and due to the cause(s) stated. (Signature nd Title) 2 Ryan D. Crouch, DO 24e. 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 Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES El NO 0 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 Prin Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803 12 8a REGISTRAR'S SIGNATURE � - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I August 30, 2013 WHEN 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 WITI-P'THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS ,THE LEGAL DEPOSITORY FOR ,VITAL REXORPS, DATE OF ISSUANCE 09/03/2013 STATE OF NEBRASKA 201307645 STANLEY S. COOPER ASSISTANT STATE REGISTRAR; DEPARTMENT OF HEALTH AND LINCOLN, NEBRASKA ,HOMAtk SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES.` • CERTIFICATE OF DEATH ,.' . f.