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To be completedNerlfled by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Lillian R Herman 2. SEX - ;! t Female , " 3.0ATE O'F DEATH (Mb., Day, Yr.) July, 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Prosser, Nebraska 5a. AGE - Last Birthday (Yrs) 101 5b. UNDER 1 YEAR 5e. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) February 10, 1912 MOS. I DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -58 -8563 8b. FACILITY -NAME (If not Institution, give street and number) Good Samaritan Society-Wood River 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 1401 East Street e. APT. NO. r 9f. ZIP CODE I 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) tf wife, give maiden name Harvey Herman 11. FATHER'S -NAME (First, Middle, Last, Suffix) Clarence Cox 12. MOTHER'S -NAME (First, Middle, Maiden Surname) August Engel 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Jerry Rainforth 14b. RELATIONSHIP TO DECEDENT Son 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Randy Gubser 16b. LICENSE NO. 0948 16c. DATE (Mo., Day, Yr.) July 20, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Rosedale Cemetery Rosedale Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Brand - Wilson Funeral Home, 505 N Bellevue, Hastings, Nebraska 17b. Zip Code 68901 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 15. PART 1. 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 > 1 Yr 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) End Stage Dementia disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially het conditions, if b) Vascular Dementia - Alzheimers Type > 10 Yrs any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Chronic Cerebrovascular Disease > 20 Yrs (disease or injury that initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) Advanced Age 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 151,1 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 215. MANNER OF DEATH ® Natural ❑ Homicide ❑ Acddent ❑ Pending Investigation Suicide Could not be determined ❑ ❑ 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? 0 YES ID NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? TO ❑ 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 N1 1 g } g e z 23a. DATE OF DEATH (Mb., Day, Yr.) July 17,2013 z1 ! e. 4 8 w B p o § ` 3 s 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) July 18, 2013 23c. TIME OF DEATH I 05:25 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 0 0 3d. To the best of my knowledge, death occurred at the time, date and place B o and due to the cause(s) stated. (Signature and Title) o m 2 Steven Husen, 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 IZI NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print . Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Islan e Nebraska, 68803 I28a. REGISTRAR'S SIGNATURE - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) July 19, 2013 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANQI-kUtl SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASK4,t3EP TMNh QF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL bkDS' ; # • DATE OF ISSUANCE 07/30/2013 LINCOLN, NEBRASKA 201 401362 SIAiggY ©OOPER ASSISTANCE E FRA DEPARTM HUMA( SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER1/ICOS' I CERTIFICATE OF DEATH ` ;�a ''13 03070