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To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Gloria Ann Hanna 2. SEX Female 3, DATE OF DEATH (Mo., Day, Yr.) February 14, 2011 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Wayne, Nebraska 5a. AGE • Last Birthday Mc) 50 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) June 3, 1960 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -92 -5519 8b. FACILITY -NAME (If not Institution, give street and number) 11580 South Cameron Road 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) Wood River 68883 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Wood River 9d. STREET AND NUMBER 11580 South Cameron Road e. APT. NO. r 9f. ZIP CODE 68883 9g. INSIDE CITY LIMITS ❑ YES ® NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Scott J Hanna 11. FATHER'S -NAME (First, Middle, Last, Suffix) Allen Splittgerber 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Lorna Heermann 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT•NAME Scott J Hanna 14b. RELATIONSHIP TO DECEDENT Husband 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.) February 15, 2011 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) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 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 2 Weeks 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) Liver Failure disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Graft VS. Host Disease 3 Months any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Stem Cell Transplant 1 Year (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d)Acute Myelocytic Leukemia 1 Year 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting In the underlying cause given in PART I. 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 ❑ Peni rtion ❑ Suicide ❑ Could determined 21b. IF TRANSPORTATION INJURY ❑ DriverlOperator ❑ 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 ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE S W t ,_ E z 23a. DATE OF DEATH (Mo., Day, Yr.) February 14, 2011 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 124a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) February 15, 2011 23c. TIME OF DEATH 12:00 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) _ 24d. TIME PRONOUNCED DEAD 8 g 0 9d. To the best of my knowledge, death occurred at the time, date and place 8 3 and due to the cause(s) stated. (Signature and Title) z Nick Hartl, 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(a) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN I 26a. HAS ORGAN OR I ❑ YES ISSUE DONATION BEEN CONSIDERED? IZI NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OFCERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT , CORONER'S OR COUNTY A Nick Hartl, MD, 412 W. 42nd Street, Kearney, Nebraska, 68845 ORNEY) (Type or Print) 128a. REGISTRAR'S SIGNATURE /1� / //� ... { ,� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I February 16, 2011 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL - I • AND HU .MAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA' DEPARTMENT OFHEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR' VITAL RECO�RDS. / • DATE OF ISSUANCE 02/18/2011 LINCOLN, NEBRASKA 201309690 STANLEY S C O O P E R ' ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 11 00479