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STATE OF NEBRASKA
<br /> WHEN.THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND-HUMAN,SERVICES,IT CERTIFIES
<br /> • THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASK#1*PARTMENT'OR HEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL,RECORD$: ' "
<br /> DATE OF ISSUANCE
<br /> 12/22/2011
<br /> 201406260 STANLEY S. COOPER .
<br /> ASSISTANT STATE REGISTRAR,'
<br /> DEPARTMENT OF-HEALTH AND '
<br /> LINCOLN, NEBRASKA HLIMAN'SERVICES
<br /> STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICE'S " 11 04223
<br /> CERTIFICATE OF DEATH `" J 1
<br /> ... 1.DECEDENT'S-NAME (First, Middle, Last, Suffix) 2.SEX 1,-, ,'13.DATE OF DEATH(Mo.,Day,Yr.) '
<br /> Betty LaJean Spiehs Female '". ' December 17,2011
<br /> 4.CITY AND STATE OR TERRITORY,OR FOREIGN COUNTRY OF BIRTH 5a.AGE•Last Birthday b.UNDER 1 YEAR 5c.UNDER 1 DAY 6.DATE OF BIRTH(Mo.,Day,Yr.)
<br /> (Yrs.) MOS. I DAYS HOURS I MINS.
<br /> Grand Island,Nebraska 79 January 13, 1932
<br /> 7.SOCIAL SECURITY NUMBER 8a.PLACE OF DEATH
<br /> 507-32-8918 HOSPITAL ❑Inpatient OTHER ®Nursing Home/LTC ❑Hospice Facility
<br /> 8b.FACILITY-NAME(If not Institution,give street and number) ❑ER/Outpatient ❑Decedent's Home
<br /> et
<br /> 1- Wedgewood Care Center ❑DOA ❑Other(Specify)
<br /> W 8c.CITY OR TOWN OF DEATH(Include Zip Code) I 8d.COUNTY OF DEATH
<br /> e Grand Island 68803 Hall
<br /> tug 9a.RESIDENCE-STATE 9b.COUNTY I9c.CITY OR TOWN
<br /> Nebraska I Hall I Grand Island
<br /> LL 9d.STREET AND NUMBER e.APT.NO. .ZIP CODE INSIDE CITY LIMITS
<br /> ▪ 516 Plum Road I 9f 68801 I 9g.M YES ❑ NO
<br /> 10a.MARITAL STATUS AT TIME OF DEATH®Married ❑Never Married 10b.NAME OF SPOUSE(First, Middle, Last, Suffix)If wife,give maiden name
<br /> !G ❑Married,but separated ❑Widowed ❑Divorced ❑Unknown Phil Dean Spiehs
<br /> 20 Suffix)FATHER'S-NAME (First, Middle, Last, Sux) 12.MOTHER'S-NAME (First, Middle, Maiden Surname)
<br /> d
<br /> • Conrad Benner Katherine Liebsack
<br /> E 13.EVER IN U.S.ARMED FORCES? Give dates of service If Yes. 14a.INFORMANT-NAME 14b.RELATIONSHIP TO DECEDENT
<br /> E
<br /> 3 (Yes,No,or Unk.)No Phil Dean Spiehs Husband
<br /> 3 15.METHOD OF DISPOSITION 16a.EMBALMER-SIGNATURE 16b.LICENSE NO. 16c.DATE(Mo.,Day,Yr.)
<br /> 2 ®Burial ❑Donation
<br /> Laurie D.Sheffield 1397 December 22,2011
<br /> ❑Cremation 0 Entombment 16d.CEMETERY,CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br /> ❑Removal ❑Other(Specify)
<br /> Grand Island City Cemetery Grand Island Nebraska
<br /> 17a.FUNERAL HOME NAME AND MAILING ADDRESS(Street,City or Town,State) 17b.Zip Code
<br /> All Faiths Funeral Home,2929 S.Locust Street,Grand Island,Nebraska 68801
<br /> CAUSE OF DEATH(See instructions and examples)
<br /> 18.PART I.Enter the chain of events-diseases,Injures,or complications-that directly caused the death.DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br /> respiratory arrest,or ventricular flbdllation without showing the etiology.DO NOT ABBREVIATE.Enter only one cause on a line.Add additional lines if necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE(Final a)PROGRESSIVE ENDSTAGE PARKINSONS DISEASE YEARS
<br /> disease or condition resulting
<br /> in death) DUE TO,OR AS A CONSEQUENCE OF: onset to death
<br /> Sequentially list conditions,If b)
<br /> any,leading to the cause listed
<br /> on line a. DUE TO,OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERLYING CAUSE c)
<br /> (disease or Injury that initiated _
<br /> the events resulting In death) DUE TO,OR AS A CONSEQUENCE OF: Onset to death
<br /> LAST d)
<br /> 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
<br /> CORONARY ARTERY DISEASE,HYPERTENSION, OR CORONER CONTACTED?
<br /> ❑YES 1-21 NO
<br /> CC
<br /> W- 20.IF FEMALE: 21a.MANNER OF DEATH 21b.IF TRANSPORTATION INJURY•21c.WAS AN AUTOPSY PERFORMED?
<br /> b.I- ❑Not pregnant within past year ®Natural ❑Homicide ❑Driver/Operator ❑ YES ® NO
<br /> ✓ 0 Pregnant at time of death ❑Accident ❑Pending Investigation ❑Passenger
<br /> a ❑Not pregnant,but pregnant within 42 days of death 0 Pedestrian 21d.WERE AUTOPSY FINDINGS AVAILABLE
<br /> ❑Not pregnant,but pregnant 43 days to 1 year before death ❑Suicide ❑Could not be determined ❑Other(Specify) TO COMPLETE CAUSE OF DEATH?
<br /> 1 ❑Unknown if pregnant within the past year ❑ YES ❑ NO
<br /> B.
<br /> 1 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)
<br /> 2 22d.INJURY AT WORK? 22e.DESCRIBE HOW INJURY OCCURRED
<br /> I--
<br /> ❑YES ❑NO
<br /> 22f.LOCATION OF INJURY-STREET&NUMBER,APT.NO. CITY/TOWN STATE ZIP CODE
<br /> 23a.DATE OF DEATH(Mo.,Day,Yr.) 24a.DATE SIGNED(Mo.,Day,Yr.) 24b.TIME OF DEATH
<br /> S W December 17,2011 g
<br /> 1 F 23b.DATE SIGNED(Mo.,Day,Yr.) 23c.TIME OF DEATH I 1 p> 24c. PRONOUNCED DEAD(Mo.,Day,Yr.) 24d.TIME PRONOUNCED DEAD
<br /> -)z; December 19,2011 I 02:15 PM a..4 t
<br /> 0 3d.To the best of my knowledge,death occurred at the time,date and place W 24e.On the basis of examination and/or investigation,in my opinion death occurred at
<br /> -.8 and due to the cause(s)stated.(Signature and Title) .8 Z m the time,date and place and due to the cause(s)stated.(Signature and Title)
<br /> W Jane A.McDonald,MD ~0 8
<br /> 25.DID TOBACCO USE CONTRIBUTE TO THE DEATH? I26a.HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b.WAS CONSENT GRANTED?
<br /> ❑YES ® NO ❑PROBABLY ❑ UNKNOWN I ❑YES ®NO Not Applicable If 26a is NO ❑YES ❑NO
<br /> 2/.NAME,rfi'LE AND ADDRESS OF CERTIFIER(PHYSICIAN,P YSICIAN ASSISTANT,CORONER'S PHYSICIAN OR COUNTY A 'FORNEY)(Type or Print)
<br /> Jane A. McDonald,MD,800 N Alpha Street,Grand Island,Nebraska,68803
<br /> 28a.REGISTRAR'S SIGNATURE j6 a 128b.DATE FILED BY REGISTRAR(Mo.,Day,Yr.)
<br /> December 21,2011
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