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To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Eunice Faye Bloomberg 2. S `FX ' 7 , , Femilel ,3.,.DATE'OF DEATH (Mo., Day, Yr.) November 27, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Osmond, Nebraska 5a. AGE - Last Birthday (Yrs.) 65 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6: DATE OF BIRTH (Mo., Day, Yr.) March 22, 1948 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -62 -9149 8b. FACILITY -NAME (If not Institution, give street and number) 250 Carey Avenue 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 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 250 Carey Avenue 19e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS M YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Herald Gene Bloomberg 11. FATHER'S -NAME (First, Middle, Last, Suffix) Cecil VonRentzell 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Anetta Hansen 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Herald Gene Bloomberg 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation tEl Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) December 2, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER I 19. 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 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) Congestive Heart Failure disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: - onset to death Sequentially list conditions, if b) High Blood Pressure Years any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Emphysema Years (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. Heart A -fib Arythmia 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 20. IF FEMALE: 0 Not pregnant within past year ❑ Pregnant at time of death 0 Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 49 days to 1 year before death ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident 0 Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 0 N 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 t I i t Y E u z 23a. DATE OF DEATH (Mo., Day, Yr.) S F, i z 0 k r IL < z Hmt w O 2 C p ' v o 24a. DATE SIGNED (Mo., Day, Yr.) December 2, 2013 24b. TIME OF DEATH Approx. 10:00 AM 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) November 27, 2013 24d. TIME PRONOUNCED DEAD 12:12 PM 8 ' 0 9d. To the best of my knowledge, death occurred at the time, date and place 8 i and due to the cause(s) stated. (Signature and Title) 12 Li n the asi oT examination and/or gation, In my opinion death occurred at 24e. O the time date s and place and due to the investi causes) state (Signature and Title) Megan Alexander, Hall Deputy County Attorney 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 If26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND OF CERTIFIER (Type or Print Megan Alexander, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 28a. REGISTRAR'S SIGNATURE /Jt A- /�_ I 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I 2, 2013 December DATE OF ISSUANCE 12/05/2013 LINCOLN, NEBRASKA STATE OF NEBRASKA 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 WITH THE NEBRA$IKA 68PAR)MMWNT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FQf3' VITALECCSRDS.' 1 t 201309615 STANLEY S.-COOPER • ASSISTANT STATE REGISTRAR " DEPARTMENT OF HEALTH ANd HUMAN SERVICES ' STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN,SERVICES :. CERTIFICATE OF DEATH 13 05138