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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Lydia Anna Severson 2. SEX . 1 • ,,J l , Female t A. di'" DEATH (Mo., Day, Yr.) ' ' FeLWacll17, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Valley County, Nebraska 5a. AGE - Last Birthday (Yrs.) 91 5b. UNDER 1 YEAR 5c. UNDER 1 DAY , 6: pAtE OF BIRTH (Mo., Day, Yr.) January 20, 1923 MOS. DAYS 'HOURS MINS. = 7. SOCIAL SECURITY NUMBER 506 -26 -1172 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center 8a. PLACE OF DEATH HOSP ® 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 " 8d. COUNTY OF DEATH' ' Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY I Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 211 West 18th e. APT. NO. r 9f. ZIP CODE I 68801 9g. INSIDE CITY LIMITS I ® 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 Donald L Severson 11. FATHER'S -NAME (First, Middle, Last, Suffix) Emil Mathauser 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Anna Rousek 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Donald L Severson 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Chris McCoy 16b. LICENSE NO. 1191 16c. DATE (Mo., Day, Yr.) February 19, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Ord City Cemetery Ord 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 I 18. PART I. Enter the chain of events -- diseases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, r APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Urosepsis And Pneumonia disease or condition resulting onset to death 5 Days In death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list condidone, if b)Chronic Urinary Incontinence I 2 Years any, leading to the cause listed I I on fine e. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) I (disease or injury that initiated I the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LAST d) 1 1 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART I. Hypothyroidism, Bullous Pemphigus 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 ID 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 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE " W F 23a. DATE OF DEATH (Mo., Day, Yr.) February 17, 2014 ; g ' W 0 24o $ C G o It, 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH- - - - 23b. DATE SIGNED (Mo., Day, Yr.) February 18, 2014 23c. TIME OF DEATH I 04:45 AM 2 4c . PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD u O 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Tito) 12 f Adam Brosz, MD On the basis of examination and/or Investigation, in my opinion death occurred at the ti date and place and due to the cause(*) stated. (Signature and Title) 25. IND 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 Adam Brosz, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803 1 28a. REGISTRAR'S SIGNATURE A - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) February 19, 2014 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ALz kl, L,(4' AN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASJ9CD PART ENT1OF HEALTH AND R HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FO,ITA4, RECbRLdS:. , t DATE OF ISSUANCE STATE OF NEBRASKA 201407961 SrTOICECEY S. COOPER 1�S'sj$TA SiTA T4 R DEPARTMEN7i6E 4LTF LINCOLN, NEBRASKA j'U'M,nLV SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SEil VIC S.. i. , CERTIFICATE OF DEATH A r; % + " >.. • , 12/11/2014