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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEA,4WHOND,HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE151Vp<A „QE ?A4TirfENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FQR; _VtTAL ; R& QRQt': STANLEY S. COOPER, ASSISTANT$T4TE REGISTRAR OEPARTMENT.CFHEALTH AND HUMAN SERVICES DATE OF ISSUANCE 11/20/2014 LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HumANzRyicgs, CERTIFICATE OF DEATH , 14 05924 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Helen K Skeen g. SEX Feiriale . 3. DATE OF DEATH (Mo., Day, Yr.) - ."November 13, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Wood River, Nebraska 5a. AGE - Last Birthday (Yrs.) 76 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) October 1, -1938 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506-46 -0934 8b. FACILITY -NAME (If not Institution, give street and number) 12500 Cedarview Road 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) Wood River 68883 ad. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Wood River 9d. STREET AND NUMBER 12500 Cedarview Road 9e. APT. NO. 9f. ZIP CODE 68883 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 Gerald Skeen 11. FATHER'S -NAME (First, Middle, Last, Suffix) William W Filkin 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Esther Bennett 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Gerald Skeen 14b. RELATIONSHIP TO DECEDENT Spouse 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.) November 17, 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) Apfel Funeral Home, 411 W 11th St., Box 126, Wood River, Nebraska 17b. Zip Code 68883 CAUSE OF DEATH (See instructions and examples) 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 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) Unknown Natural Causes disease or condition resulting onset to death Hours in death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death Sequentially list conditions, if b) Aging I Years any, leading to the cause listed t 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: I onset to death LAST d) 1 1 1 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. History Of Myocardial Infarction, Ataxia, Neuro Disorder, NOS 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 ID 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 El 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? DYES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE a W i r ° Z 23a. DATE OF DEATH (Mo., Day, Yr.) L' (I = e ° 4 Z `S' w o 8 0 u le g s 24a. DATE SIGNED (Mo., Day, Yr.) November 17, 2014 24b. TIME OF DEATH Approx. 12:00 AM 23b. DATE SIGNED (Mo., Day, Yr.) 1 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) November 14, 2014 24d. TIME PRONOUNCED DEAD 01:10 PM 0 3d. T o the beat of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) l Ill 24e. On the bash of exami and/or eation, in my opinion ath occurred at the time, date and place nation and due to Inv the cau stated. (Signature and Title) Nancy Berger- Schneider, Hall Deputy County Attorney 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 Nancy Berger- Schneider, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 128a. REGISTRAR'S SIGNATURE A - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) November 19, 2014 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEA,4WHOND,HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE151Vp<A „QE ?A4TirfENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FQR; _VtTAL ; R& QRQt': STANLEY S. COOPER, ASSISTANT$T4TE REGISTRAR OEPARTMENT.CFHEALTH AND HUMAN SERVICES DATE OF ISSUANCE 11/20/2014 LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HumANzRyicgs, CERTIFICATE OF DEATH , 14 05924