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To Be Completed/Verified by: FUNF AL-DIRE&ii9R ---- 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) ,, Blanche Agatha Waters 2. SEX ` ` Female '4. DATEOF DEATH (tii& bay,Yr.) October 3, 2009 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Loup City, Nebraska Se. AGE -Last Birthday (Yes.) 87 5b. UNDER 1 YEAR 6c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) MOS. DAYS HOURS MINS. _ ,rll 6, 1922 7. SOCIAL SECURITY NUMBER 508 -12 -7900 8a. PLACE OF DEATH ismicrAL: lE Inpatient QIynB; Nursing Homelt.TC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home Other 0 DOA 0 /Specify) fib. FACILITY -NAME (If not institution, give street and number) St Elizabeth Regional Medical Center 8e. CITY OR TOWN OF DEATH (Include Zip Code) Lincoln 68510 ad. COUNTY OF DEATH Lancaster 94. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1009 West Louise 9e. APT. NO. 9E ZIP CODE 68801 9g. INSIDE CITY LIMITS ® Yee ❑ No 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unimown 1116. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Richard Waters 11. FATHER'S -NAME (First, Middle, Last, Suffix) John J Golus 12. MOTHER'S -NAME (First, Middle, Malden Surname) Anna Tutaj 13. EVER IN U.S. ARMED FORCES? Give dabs of service I Yea. (Yea, No, or Unk.) No 144. INFORMANT -NAME Richard Waters 14b. RELATIONSHIP TO DECEDENT Husband 16. METHOD OF DISPOSITION ® Dud" ❑ D°" ' "°" DOlautio Rantovd ^ 16a. L / ' TURE / .,0 k. T 16th. LICENSE NO. / f 7 - 16c. DATE (Mo., Day, Yr.) October 9, 2009 16d. CEMETE I , CREMATORY OR OTHER L ATION CITY/TOWN STATE Fairview Cemetery Lincoln Nebraska - 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Stab) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 To Be Completed by: CERTIFIER CAUSE OF DEATH (See Instructions and examples) 1a. PART L Enter the AludstritundiE - dress, Inhales, or complications-MR dimity caused the dMh DO NOT enter Smiled events such as cardiac mist. APPROXIMATE INTERVAL resplrste,y west, ni /kr flbriliston without mowing the etiology. DO NOT AaARMUM1TE.: Enter anyone cause on • Rea Add eddittond umc N mummy. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final s1 disease or condition resulting a) C 6 in death) \ y DUE TO, OR Sequentially not conditions, a g b the cause Nabd b) AS A CONSEQUENCE OF onset to death /, 4 % 4.9 1J`,p .^iS on l ne a. °^ line a. DUE TO, Enter the UNDERLYING CAUSE c) A CONSEQUENCE OF: onset to dO (disease or injury that initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART IL OTHER SIGNIFICANT CONDITIONS-Con pontdbu g to the d but not resulting M the underlying cause ghren In PART L .1)11'4;3E. o Vt.- 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ly NO 20. IF FEMALE: of 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 dealt ❑Unknown If pregnant within the pest year 214. MANNER OF DEATH gyatural ❑ Homicide Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ DrivedOperator ❑ Passenger ❑ Pedestrian ❑ Other (Speely) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES lif NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ yes ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction sits, ate. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22a. DESCr61E HOW INJURY OCCURRED - 22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE d yW a r iti � c 23a. DATE OF DEATH (Mo, Day, Yr.) 3 -0 q 1 .51 _www > O E�az O a p FOt` V O 244. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. D SIGNED (Mo., Day, Yr.) /0 --6--o 23c. TIME OF DEATH //�� OO1Csr/rin 24c. PRONOUNCED DEAD (Mo, Day, Yr.) 24& TIME PRONOUNCED DEAD m o a 23d. To the best of my knowledge, death occurred at the time, data and place •S a h1,h and to the camps) stated. (S1 Title) 1 0 - Ss 24s. On the thesis of examination andlor InvssNgadcn, In my opinion death aeeuned at tlu rims, slab and place and rise to tlta ealm(s) stated. (Slgnature and Tltly 25. DID TOBACCO USE CONTRIB TO THE DEATH? II YES El ❑ PROBABLY ❑ UNKNOWN 260. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ffi NO 26th. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES ❑ NO 27. NAM TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORO PHYS IA OR C C�� 1��narr� s Alin UNTY A .' (Type or Print) C t�� l u U 6�tta 28a REO NATURE 286. DATE FILED BY REGISTRAR (Mo., Dq, Yr.) ji Le /0). AO � - OCT 0 7 2009 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'D € ENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VI Az , eaR. QS.' i DATE OF ISSUANCE AUG 2 6 2014 LINCOLN, NEBRASKA 201405667 STANLEY s COOPER 4. , ;ASSISTANT STA REG!STf AR pEPAtY !7 . C FAL ". ?AND 1IW7A'M SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVES CERTIFICATE OF DEATH' � 8