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STATE OF NEBRASKA r ' WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAChr THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH 17lE NaRRSKAbERAR1 HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITOR Y• VLTA '43FGQkDS DATE OF ISSUANCE 09/20/2013 STA11LY.4. COOPER ` a � ASSISTANT A E REGIITtA4R RTMg NT 14EALT&Af4D' LINCOLN, NEBRASKA UMeAN SERVICES` ,` ' -Z v , STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S IC S ; 13 03992 CERTIFICATE OF DEATH , 201308792 SERVICES, IT CERTIFIES T -F HEALTH AND 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Rhoda Elizabeth Caswell 2. SEX§,», Female ,; 3. DATE OF DEATH (Mo., Day, Yr.) - September 14, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Albion, Nebraska 5a. AGE - Last Birthday (Yrs. 88 5b. UNDER 1 YEAR 5c. UNDER 1 DAY a . 8. DATE OF BIRTH (Mo., Day, Yr.) June 27, 1925 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506-22 -0528 8b. FACILITY -NAME (It not Institution, give street and number) Grand Island Country House, L.L.C. 8a. PLACE OF DEATH HOSPITAL, ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ERIOutpatlent ❑ Decedents Home ❑ DOA ® Other (SpecffyyASSISTED LIVING 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE NebraskaI 9b. COU 9c. CITY OR TOWN I Cairo 402 West Syria r 9d. STREET AND NUMBER p e. APT. NO. I 9f. ZIP CODE 68824 I 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 C asey Caswell 11. FATHER'S -NAME (First, Middle, Last, Suffix) Lee Lewis Hallstead 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Rosetta Louise Hilgen 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Casey Caswell 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Chris McCoy 16b. LICENSE NO. 1191 16c. DATE (Mo., Day, Yr.) September 18, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Riverside Cemetery Crete 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) Is. PART I. Enter the chain of events -- diseases, Injuries, or complications-that directly caused the death. DO NOT emertennlnal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death 2 Years respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one awe on a line. Add additional fins H necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Myasthenia Gravis disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially Ilat conditions, if b) Chronic Cerebrovascular Disease >10 Years any, leading to the cause listed on Ilse 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. Severe Dementia, Arteriosclerotic Cardiovascular Disease 19. WAS MEDIAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO Q0. IF FEMALE: ❑ Not pregnant within past year nnt t ti f death ❑ Prega ame of ❑ Not pregnant, but pregnant whhln 42 days of dealt ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown If pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Atwldent ❑ Pending Investigation ❑ Suicide ❑Could not be determined 21b. IF TRANSPORTATION INJURY ❑ DriverlOperator ❑ Passenger ❑ Pedestrian ❑ sow (speck) 21c. WAS AN AUTOPSY PERFORMED? ❑YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABL 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 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 3' 23a. DATE OF DEATH (Mo., Day, Yr.) September 14, 2013 1 E $ u�i E = § ~ $ 3 24a. DATE SIGNED (Mo„ Day, Yr.) 24b. TIME OF DEATH 23b. D ATE SIGNED (M o., Day, Yr.) Septe mber 17, 20 13 23c. TIME OF DEATH I 10:40 PM 24e. PRONOUNCED DEAD (MO., Day, Yr.) 24d. TIME PRONOUNCED DEAD g 3d To the best of my knowledge, death occurred at the time, date and p E _ and due to the cause(a) stated. (Signature and Title) Steven Husen, MD 24e. On the bests of examination a dlor investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and MN) 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 H 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Fri Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 p28a. REGISTRAR'S SIGNATURE A 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) September 18, 2013 STATE OF NEBRASKA r ' WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAChr THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH 17lE NaRRSKAbERAR1 HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITOR Y• VLTA '43FGQkDS DATE OF ISSUANCE 09/20/2013 STA11LY.4. COOPER ` a � ASSISTANT A E REGIITtA4R RTMg NT 14EALT&Af4D' LINCOLN, NEBRASKA UMeAN SERVICES` ,` ' -Z v , STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S IC S ; 13 03992 CERTIFICATE OF DEATH , 201308792 SERVICES, IT CERTIFIES T -F HEALTH AND