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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTti,AN10 -F UMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEERASKA DEPARMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY,QOR V1TAL'RECORDS.` ` Inavale, Nebraska 7. SOCIAL SECURITY NUMBER 505 -34 -1279 DATE OF ISSUANCE MAR $ g 2014 LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First Middle, Last, Suffix) Eileen May Richardson 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 8b. FACILITY-NAME (H not Institution, give street and number) 5 Saint Francis Medical Center Hospice 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 113 Apple Lane 1B. METHOD OF DISPOSITION ❑Burial ❑Dentition 12 Cremation DEntombment ❑ ❑ Removal Other(epedy) STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES C RTIFICAT • F DEATH 9b. COUNTY Hall 11. FATHER'S -NAME (First. Middle, Last, Suffix) Earl Portenier 1aa. EMBALMER - SIGNATURE Not Embalmed 201402309 8a. AGE-Last Birthday (TIP.) 80 10a. MARITAL STATUS AT TIME OF DEATH ® Married ffix) N ed ❑ Never Married l 10b. NAME OF SPOUSE (First, Middle, Last, Su wife, give maiden name. ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. i 14a. INFORMANT -NAME (Yes, No, or link.) NO John Richardson John Richardson 18d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Memorial Park Crematory 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livingston - Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska CAUSE OF DEATH (See Instructions and examples) 10. PART I. Enter the TJlein o/ events - disuses, Injuries, or complication.. Mal tinselly caused nu death. 00 NOT entertenelnal events such as cardiac arrest, arrest, ast, or vennkular Mediation without showing the etiology. DO NOT ABBREVIATE Enter only one cause on • Ilne. Add additional Ones N necessary. IMMEDIATE CAUSE (Final disease or condition resulting in death) 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? ❑ YES ❑ NO IMMEDIATE CAUSE: . DATE OF DEATH (Mo., Day, Yr.) March 5, 2008 2121., DATE SIGNED (Mo., Day, Yr.) AA., 5, 2008 28a. REGISTRAR'S SIGNATURE DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, N any, leading to the cause listed " on fine a. DUE TO, OR AS A cONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or Injury that initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) ART II. OTHER SIGN�IFI�aNT 9ONDITIONS- Conditions contributing to data but n resuidng yt the underlying exam given in PART I. / , aA 7,0 7'l+ , �(4/ror •e Y: ? FEMALE: Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 41 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑Unknown If pregnant within the pest year 22f. LOCATION OF INJURY • STREET It NUMBER, APT. NO. MANNER OF DEATH Natural ❑ Homicide ., %r ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22b. TIME OF INJURY 122c. PLACE OF INJURY -At home, farm, street, factory, office building, construction sits, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED y 0d. TIME OF DEATH / 03:40 a CITY/TOWN e m 2 the best of my knowledge, death occurred at the time, data and place and due to th 9p�tbSe(Ji) statel nature an Tltia) 4¢ DID TOBT USE CONTRIBUTE TO THE DEATH? AN. HAS ORGAN OR TI ❑ YES NO 0 PROBABLY 0 UNKNOWN ❑ YES . 9b. UNDER 1 YEAR M08. 9o. CITY OR TOWN Doniphan DAYS 8a. PLACE OF DEATH HOSPITAL: 0 Inpatient ❑ ER/Outpatient ❑ DOA 12. MOTHER'S -NAME (First, Irma Reeve 2. SEX lab. LICENSE NO. CITY/TOWN Grand Island 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 24a. DATE SIGNED (Mo., Day, TO 24c. PRONOUNCED DEAD (Mo., Day, Yr.) DONATION BEEN CONSIDERED? NO AIAZme, TITLE AND ADDRESS OF CERTIFIER (PHYSIC ORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Dr Jane McDonald 800. Alpha Grand Female Sc. UNDER 1 DAY HOURS 9d. COUNTY OF DEATH Hall STANLEY S. .COOPER ,ASSISTANT STATE REGISTRAR .DEPARTMENT CE H,EALTti AND - SERVICES PAINS. 1 99. APT. NO. 19f. ZIP CODE Middle, Maiden Surname) 22 78 DATE OF DEATH (M0.,Day,Yr.) March 5, 2008 9. DATE OF BIRTH (Mo., Day, Yr.) March 20, 1927 OTHER, ❑ Nursing Home/LTC ® Hospice Facility ❑ Decedent's Hone ❑ OHer(SpecIfy) 9g. INSIDE CITY LIMITS 68832 I ❑ Yes ® No Husband 111c. DATE (Mo., Day, Yr.) March 5, 2008 onset to death 14b. RELATIONSHIP TO DECEDENT APPROXIMATE INTERVAL. 0 i.6+GdRw¢ to death onset to death onset to death )19: WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ❑ NO 210. WAS AN AUTOPSY PERFORMED? ❑ YES NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑YES fio NO , STATE ZIP CODE 24b. TIME OF DEATH 2alh WAS CONSENT GRANTED? Not Applicable N 20a Is NO ❑ YES STATE Island, NE 68803 Nebraska 17b. Zip Code 68803 24d. TIME PRONOUNCED DEAD 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) MAR 6 2008 m 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 Tide)