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To be completedNerified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First Middle, Last, Suffix) Bernita Jean Kennedy 2. SEX Y Female > V. bA7toF bEA.TR Mo., Day, Yr.) Apri[28, - 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Belgrade, Nebraska 5a. AGE - Last Birthday (Yrs.) 87 5b. UNDER 1 YEAR _ 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) October 3, 1925 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -24 -2354 8b. FACILITY -NAME (If not Institution, give street and number) 4314 Blauvelt Rd 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 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9e. CITY OR TOWN I Grand Island 9d. STREET AND NUMBER 4314 Blauvelt Rd e. APT. NO. 9f. ZIP CODE I 68803 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 Melvin James Kennedy 11. FATHER'S-NAME (First, Middle, Last, Suffix) Henry Schoening 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Zella Ostrander 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Janet Husman 14b. RELATIONSHIP TO DECEDENT Daughter 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.) April 28, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Nebraska Anatomical Board Omaha Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livingston - Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska for Nebraska Anatomical Board, 986395 Nebraska Medical Center, Omaha, Nebraska 17b. Zip Code 68803 68198 -6395 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 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) Systemic Scleroderma 25 Years any, leading to the cause listed line on 8. 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 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Hypothyroid, Hypertension, Atrial Fibrillation, CVA, Vitamin D Deficiency 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 ❑ Sulfide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES lij 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 b' I z 23a. DATE OF DEATH (Mo., Day, Yr.) April 28, 2013 ;;' s 4 y E ° < _ e , o 8 w 8 g Z 5 ~ 5 s 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) May 14, 201 23c. TIME OF DEATH I 03:40 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 2 0 3d. To the best of my knowledge, death occurred at the time, date and place and due to the causes) stated. (Signature and Title) a Kimberly A. Mickels, MD 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 ® 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 28a. REGISTRAR'S SIGNATURE /� j A- /' 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I May 16, 2013 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH A IIt/MAII( SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKIPDE , I T 1 N , !9F tIALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIAL ECORDS r • c F DATE OF ISSUANCE l /, rte.. - - - V ,.. ' STANLEY S. COOPER ,, ASS75T.AN T 4TE REGISTRAK 1 e D pAR7.ME af HEALTH AND' . ; LINCOLN, NEBRASKA HUM*N STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES' •...< r ) . CERTIFICATE OF DEATH ' 4 i . ' • • • • • 05/28/2013 STATE OF NEBRASKA 241 308625 "13 02130