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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 NEBRASKA`DEPART ,ENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITA. IRECOROS. DATE OF ISSUANCE 07/22/2013 201309694 'STANLEY S . t -' ASSISANT STATE REGISTRAR D PA ONT�(11F'IEALtH'AND LINCOLN, NEBRASKA , tiUMA J SERVICES - • STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SgRVIDE§ CERTIFICATE OF DEATH 13 03079 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Jessie Mae Campbell 2. SEX' :' . `' Female ' BATE OF DEATH (Mo., Day, Yr.) July 18, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Kansas City, Kansas 5a. AGE - Last Birthday (Yrs.) 66 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.) June 20, 1947 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 509 -46 -9270 8b. FACILITY -NAME (If not institution, give street and number) Park Place -A Golden Living Center 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 305 Commanche Avenue e. APT. NO. r 9f. ZIP CODE I 68803 9g. INSIDE CITY LIMITS g 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 11. FATHER'S -NAME (First, Middle, Last, Suffix) Walter Jackson Campbell 12. MOTHER'S -NAME (First, Middle, Malden Surname) Joy Cox 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Angela Hanson 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.) July 19, 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 for Central Nebraska Cremation & Mortuary Service 609 Front Street, PO Box 280, Gibbon, Nebraska 17b. Zip Code 68801 68840 CAUSE OF DEATH (See instructions and examples) 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 10 Days respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add additional lines If necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Sepsis disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) Pyelonephritis 10 Days any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Diabetes 20 Years (disease or injury that Initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) Obesity 40 Years 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART I. Depression ,Congestive Heart Failure, 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 20. IF FEMALE: ® Not pregnant within past year 0 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 ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® 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? DYES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE o LL cc a E E . 23a. DATE OF DEATH (Mo., Day, Yr.) July 18, 2013 1. 9 E I E k ,. E y' Z 8 w i G 2 = p '" 0 3 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) Jul 18, 2013 23c. TIME OF DEATH 03:00 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 0 3d. To the best of my knowledge, death occurred at the time, date and place 2 and due to the cause(s) stated. (Signature and Title) f Larry L. Hansen, 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 Larry L. Hansen, MD, 3016 West Faidley, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE / / h (� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I July 19, 2013 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 NEBRASKA`DEPART ,ENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITA. IRECOROS. DATE OF ISSUANCE 07/22/2013 201309694 'STANLEY S . t -' ASSISANT STATE REGISTRAR D PA ONT�(11F'IEALtH'AND LINCOLN, NEBRASKA , tiUMA J SERVICES - • STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SgRVIDE§ CERTIFICATE OF DEATH 13 03079