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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Delores Gascho 2'.. SEX , R Female rti DATA ; OR DEATH (M0'.; Day, Yr.) f INovemberr24, 2011 ' 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Beaver Crossing, Nebraska 5a. AGE - Last Birthday (Yrs.) 88 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) October 18, 1923 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -28 -5687 8b. FACILITY -NAME (If not Institution, give street and number) Westem Hall County Good Samaritan Center 8a. PLACE OF DEATH HOSPITAL, ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedents 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 1401 East Street I9e. APT. NO. 8f. ZIP CODE f 68883 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 Glen Gascho 11. FATHER'S -NAME (First, Middle, Last, Suffix) Meno Schweitzer 12. MOTHER'S •NAME (First, Middle, Maiden Surname) Cassie Stutzman 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Dave Gascho 14b. RELATIONSHIP TO DECEDENT Son 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.) November 29, 2011 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Wood River Mennonite Cemetery Wood River 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 Days 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) Debility Unspecified disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially fist conditions, if b) Coronary Artery Disease Years any, leading to the cause listed line a. on 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 t resulting In the underlying cause given in PART I. History Of Breast Cancer, Osteoporosis, Chronic Pain Syndrome, Hypertension 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 ❑ AcckleM ❑Pen rtlon ❑ Suicide ❑ Could 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 2 W } E E 23a. DATE OF DEATH (Mc., Day, Yr.) November 24, 2011 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. 1 IME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) November 30, 2011 23c. TIME OF DEATH ( 10 :45 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD o 8 S 0 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cauae(s) stated. (Signature and TRIe) 2 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? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN I 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? I ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, ISITYSTC!AN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 ORNEY) (Type or Print) I28a. REGISTRAR'S SIGNATURE /L+ / ^ - /� /�� / (, 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I December 1, 2011 DATE OF ISSUANCE 12/05/2011 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF'HEALTH ANQ HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE$RAS DEPAI7i11MENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITOIW FOf o VVT�?4 ECO . r /...n • 201309836 r r Si4V 14•E9I MEW QF%$4 f3 LINCOLN, NEBRASKA "i IfAN'ugl6(IGE; STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN $siiyades% '�` ' » CERTIFICATE OF DEATH , ,,,F', 03968