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I To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Betty Louise DeMary 2!SEX ( p � ' , • ,S. DEATH (Mo., Day, Yr.) - March J, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Tarkio, Missouri 5a. AGE • Last Birthday (Yrs.) 77 5b. UNDER 1 YEAR 5e. t)NDER` I, DAY: 6: D &TE'OF BIRTH (Mo., Day, Yr.) ¢ September 17, 1936 MOS. I DAYS HOURS MMS �� 7. SOCIAL SECURITY NUMBER 508 -38 -8256 8b. FACILITY -NAME (If not Institution, give street and number) Wedgewood Care 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 8d, COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 621 N. Gunbarrel Road e. APT. NO. r 9f. ZIP CODE I 68801 9g. INSIDE CITY LIMITS ❑ YES ® NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name George Arthur DeMary 11. FATHER'S -NAME (First, Middle, Last, Suffix) Harold Wolf 12. MOTHER'S -NAME (First, Middle, Malden Surname) Veda Courtney 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Link.) No 14a. INFORMANT -NAME George Arthur DeMary 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 16e. DATE (Mo., Day, Yr.) March 10, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING 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 15. 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 cause on a line. Add additional lines If necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Dementia Of The Alzheimers Type disease or condition resulting In death( DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially Ilst conditions, if b) any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE C ) (disease or Injury that Initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death ` ' not resulting In the underlying cause given In PART I. Hypertension, Vitamin D Deficiency, Osteoporosis, H/O Breast Cancer, Pulmonary Mass On CT 11/13, Pulmonary Embolism 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El 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 ❑Pent lion ❑ Suicide ❑ Could 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 construction site, etc. (Speciy) 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 ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE e i 1 E Y I u E 23a. DATE OF DEATH (Mo., Day, Yr.) March 7, 2014 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) March 10, 2014 I 23c. TIME OF DEATH 12:44 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 0 0 9d. To the hest of my knowledge, death occurred at the time, date and place 6 and due to the cause(s) stated. (Signature and Title) a Kimberly A. Mickels, MD 24e. On the basis of examination and/or Investig tion, 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? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable H 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Kimberly A. Mickels, MD, 729 North Custer Avenue, , Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE /�� ' / 1 A _ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) March 11, 2014 STATE OF NEBRASKA BOOK ,13 PAGE gZ 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 J(IT.AL'sREcQRDS. /ktr DATE OF ISSUANCE 03/17/2014 201500848 LINCOLN, NEBRASKA TANT STATE REGISTJ Aft TMEA,T OF IYEALTI4 A.'VD Hu "'"AOR ll(ICf S STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES - . CERTIFICATE OF DEATH