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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Tamara Jean DeMers 2. SEX, a • •,'r Fem .f ' • 3. At, F 1o„,�Uay, Yr.) `. ":0,Clober 2 20yi` 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Neligh, Nebraska 5a. AGE - Last Birthday (Yrs.) 54 5b. UNDER 1 YEAR 5c. UNDElk 1jDAY ✓' 4q. 9ATjE Ot 131074/101o., Day, Yr.) � M �� September 26, 1959 MOS. DAYS I HOURS MI S. 7. SOCIAL SECURITY NUMBER 507 -74 -9317 8b. FACILITY -NAME (If not Institution, give street and number) 4311 Manchester Rd. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Home ❑ DOA ❑ Offmr (SP.clfy) 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 re. APT. NO. I 4311 Manchester Rd. 9f. ZIP CODE 68803 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 Doug DeMers 11. FATHER'S -NAME (First, Middle, Last, Suffix) Donald Koskovich 12. MOTHER'S -NAME (Flat, Middle, Maiden Surname) Delores Joston 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or link.) No 14a. INFORMANT -NAME Doug DeMers 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Patricia R. Curran 16b. LICENSE NO. 1092 16c. GATE (Mo., Day, Yr.) October 28, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH Mee instructions and examples) To be completed by: CERTIFIER 18. PART 1. Enter the chain of events -- diseases, Injuries, or cempltcations-tbat directly caused the death. DO NOT enter terminal 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 cause on a line. Add additional Tines if necessary. IMMEDIATE CAUSE IMMEDIATE CAUSE (Final a) Breast Cancer disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: . onset to death Sequentially list conditions, If b) any, leading to the cause listed Tine on 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 11. OTHER SIGNIFICANT CONDITIONS- Condltlons contributing to the death but not resulting In the underlying cause given In PART 1. 19. WAS MEDICAL. EXAMINER OR CORONER CONTACTED? ❑ YES 15:1 NO 20. IF FEMALE: 0 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 ❑Peru lion ❑ Suicide ❑ Could determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ 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? DYES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CRYITOWN STATE ZIP CODE W 1 g 1 c, Z 23a. DATE OF DEATH (Mo., Day, Yr.) October 23, 2013 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) October 24, 2013 23c. TIME OF DEATH I 05:45 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 0 . To the best of my knowledge, death occurred at the time, date and place 2 c and due to the ause(s) state (Signature and Tftle) ~ W Donald Wirth, 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 Donald Wirth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE /)L„ 9 A /� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 29, 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 DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL REC DATE OF ISSUANCE 10/30/201 LINCOLN, NEB q ' STANl &''S >✓�cW l>s n .v�`. i ! i 3 201400760 AS,.QrA11 T gTATE REGISTRAli', DE PJMENT OF ANDS / NEBRASKA HCIMM SRI?! STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIdS CERTIFICATE OF DEATH ; : , 1 04610