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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Shelly Ann Heusel 2. SEX 1 Female I '• TT (Mo„ Day, Yr.) ; Ftif]k t1 CfH 0,, 3, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 58 5b. UNDER 1 YEAR 5c. UNDER 1 DAY •' 6. D ATE OF BIRTH (Mo., Day, Yr.) November 22, 1955 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -78 -9235 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center 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) Grand Island 68803 eat. COUNTY OF DEATH I Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 3103 Memphis PL e. APT. NO. 9f. ZIP CODE I 68803 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) If wife, give maiden name Steve Lynn Heusel 11. FATHER'S -NAME (First, Middle, Last, Suffix) Marshall Forst 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Norma Arterburn 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Steve Lynn Heusel 14b. RELATIONSHIP TO DECEDENT Husband 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.) October 3, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 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 onset to death Years respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one caws on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Cor pulmonale disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, It b) Pulmonary Hypertension 1 Years any, leading to the cause listed I I on line a. DUE TO, OR AS A CONSEQUENCE OF: r onset to death Enter the UNDERLYING CAUSE c) Sarcoidosis 1 Years (disease or injury that initiated ; the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) 1 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Chronic Hypercapnic Respiratory Failure, COPD, Obesity 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 pad 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 13B NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE ;; $ t r E Z 23a. DATE OF DEATH (Mo., Day, Yr.) October 3, 2014 S I Y n 6 6 W .0 p p °. g s 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) October 3, 2014 23c. TIME OF DEATH I 06:10 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 2 S O 9d. To the best of my knowledge, death occurred at the time, date and place o Yd and due to the causes) stated. (Signature and Title) ' N Jay C. Anderson, MD 24a On the basis of examination and/or Investigation, in my opinion death occurred at the time, date and place and due to the cause(a) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ®NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO 0 YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 6, 2014 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH INDH SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA'DEP T'MENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOQ,U'ITAC• EC RbS DATE OF ISSUANCE STANLEY S. COOPER 4S5 STAIIChT z AT18E REGISTI ,AR;' D PARTmeN7`.Df.{E,1 /TH j4ND ; LINCOLN, NEBRASKA HUN4N SERVICES 41.1 1 rrts STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S ^ l r 3 �' 14 05041 CERTIFICATE OF DEATH 10/07/2014 STATE OF NEBRASKA 201406634