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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Linda Lea Whitaker 2. SEX Female 3. DATE OF DYATH (Mo., Day, Yr.) December 2, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Lexington, Nebraska 5a. AGE - Last Birthday (Yrs.) 73 6b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) January 29, 1941 MOS. DAYS HOURS MINE. 7. SOCIAL SECURITY NUMBER 506-46 -1276 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) 7501 West Lepin Road ❑ ER/Outpatient ® Decedent's Home ❑ DOA ❑ Other(Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Doniphan 68832 ed. COUNTY OF DEATH I Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Doniphan 9d. STREET AND NUMBER 7501 West Lepin Road e. APT. NO. 9f. ZIP CODE I 68832 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 James Whitaker 11. FATHER'S -NAME (First, Middle, Last, Suffix) Martin Keeler 12. MOTHER'S -NAME (First, Middle, Maiden Sumame) Velma Mundt 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME James Whitaker 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Derek Apfel 16b. LICENSE NO. 1240 16c. DATE (Mo., Day, Yr.) December 6, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE Westlawn Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 111. 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 H necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Recurrent Hypercapnic Respiratory Failure disease or condition resulting onset to death 48 Hours In death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, H b) 1 any, leading to the cause listed I 1 line on a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c ) I (disease or Injury that Initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) 1 I 1 18. PART II.OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given In PART 1. Severe Chronic Obstructive Pulmonary Disease 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE: ® Not pregnant within past year 0 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 H pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accitlent 0 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 o 6 $ E r E Z 23a. DATE OF DEATH (Mo., Day, Yr.) December 2, 2014 z y p s z I p k ,. a D W Z 8 ti p ~ § ,6 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) December 4, 2014 I 23c. TIME OF DEATH 07:51 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD O 30. To the best of my knowledge, death occurred at the time, date and place E o and due to the cause(s) stated. (Signature and Title) g Richard Fruehling, 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 Title) 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 if 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE I 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 4, 2014 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 HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR'VITAL RECORDS. DATE OF ISSUANCE STATE OF NEBRASKA STANLEY S. COOPER ' • �1SSIST.4IVT ST/ATEREGIStRAR DEPAATMEkt QE, LTH AND LINCOLN, NEBRASKA HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN` CERTIFICATE OF DEATH 12/09/2014 201407951 14 06223