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1 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Mary Louise Valasek 2. SEX t , " / / Femal4 " 3.. DATE `OF DEATH (Mo., Day, Yr.) November 16, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Palmer, Nebraska 5a. AGE • Last Birthday (Yrs) 81 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) March 7, 1932 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505-82 -5338 8a. PLACE OF DEATH HOSPITAL, ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility ❑ ER/OutpatIent ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8b. FACILITY -NAME (If not Institution, give street and number) Park Place -A Golden Living Center 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 606 N Ruby I9e. APT. NO. 9f. ZIP CODE I 68803 I 9g. INSIDE CITY LIMITS M 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 Allie Valasek 11. FATHER'S -NAME (First, Middle, Last, Suffix) Charlie Knapp 12. MOTHER'S-NAME (First, Middle, Maiden Surname) Maxine Fleshman 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME James Valasek 14b. RELATIONSHIP TO DECEDENT Son 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.) November 20, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Memorial Park Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livingston - Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 17b. Zip Code 68803 CAUSE OF DEATIT(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 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: onset to death IMMEDIATE CAUSE (Final a) Plasma Cell Dysplasia 1 Month disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b)Vitamin B 12 Deficiency 1 Month any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Renal Insufficiency 3 Years (disease or Injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART I. Recent Pneumonia, Herpes Zoster 1 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 ❑ 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? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE b''4 z 23a. DATE OF DEATH (Mo., Day, Yr.) November 16, 2013 2 1 / y g �, ` c 8 $ O 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) November 20, 2013 23c. TIME OF DEATH 06:50 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 4 0 3d. To the best of my knowledge, death occurred at the time, date and place 2 i and due to the cause(s) stated. (Signature and Title) William Landis, 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 TNN) 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 H 28a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print William Landis, MD, 2444 FFai Grand Island, Nebraska, 68803 i W. / Avenue, 128a. REGISTRAR'S SIGNATURE I { 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) November 20, 2013 Amended Amen 01/07/2014 Item 6 corrected DATE OF ISSUANCE 01/07/2014 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 1:/EALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. 2 U 1 404685 STANLEY S. COOPER ASSISTANT 4TAT R DEPARTME` / b LINCOLN, NEBRASKA HUMAN SERVICES- STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES,: / .. CERTIFICATE OF DEATH `.'