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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AN(0..
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAZKA'D�
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY IV VITALg
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Phyllis Marie Treffer
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Cicero, Illinois
<br />7. SOCIAL SECURITY NUMBER
<br />359 -18 -6239
<br />DATE OF ISSUANCE
<br />12/19/2014
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />4050 Horseshoe Place
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />4363 Sherwood Road
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married
<br />❑
<br />Married, but sepalbted ® Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Albert Brocker
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME
<br />(Yes, No, or Unk.) No Kim Harrington
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Higgins Funeral Home, 321 0 Street, PO Box 323, Loup City, Nebraska
<br />18. PART I. Enter the chain of events -- diseases, injures, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines H necessary.
<br />IMMEDIATE CAUSE:
<br />a) Myocardial Infarction
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />in death)
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disuse or injury that initiated
<br />the events resulting in death)
<br />LAST
<br />Tachycardia, Osteoporosis
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />DYES ❑ NO
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />9b. COUNTY
<br />Hall
<br />16a. EMBALMER- SIGNATURE
<br />Mark Higgins
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Unspecified Natural Causes
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />23c. TIME OF DEATH
<br />9d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />201501477
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />88
<br />28a. REGISTRAR'S SIGNATURE r id -
<br />STATE OF NEBRASKA
<br />6b. UNDER 1 YEAR
<br />MOS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Evergreen Cemetery Loup City
<br />CAUSE OF DEATH (See instructions and examples)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN ❑ YES ® NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Punt
<br />Sarah Hinrichs, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SE I VI S• +'E' Q , r -11,1 ' 4 06504
<br />CERTIFICATE OF DEATH � ? �' ""
<br />2. SEX d //J 3yDIkTE 615 (Mo., Day, Yr.)
<br />Fern a ''`1. , ,.� peceurii 12, 2014
<br />DAYS
<br />16b. LICENSE NO.
<br />1142
<br />£T INLEY S CDOPER
<br />;;1.5WFTA 7 1 ..
<br />,D0.1610
<br />OP* S RVIC
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />8d. COUNTY OF DEATH
<br />Hall
<br />OTHER ❑ Nursing Home/LTC
<br />❑ Decedent's Home
<br />® Other (Specifypaughters home
<br />19e. APT. NO. 19f. ZIP CODE
<br />68803
<br />6" are OF BIRTH (Mo., Day, Yr.)
<br />ecember 9, 1926
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Leo D Treffer
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Anna Schiddel
<br />21b. IF TRANSPORTATION INJURY
<br />O Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />N $ IT CERTIFIES
<br />N OF HEALTH AND
<br />❑ Hospice Facility
<br />1 9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />16c. DATE (Mo., Day, Yr.)
<br />December 16, 2014
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68853
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />t Immediate
<br />onset to death
<br />Hours
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I.119. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />I 22b. TIME OF INJURY 22c. PLACE OF INJURY - home, farm, street, factory, office building, construction site, etc. (Specify)
<br />1 22e. DESCRIBE HOW INJURY OCCURRED
<br />STATE ZIP CODE
<br />24a. DATE SIGHED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />December 17, 2014 Approx. 07:00 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD
<br />December 12, 2014 07:25 AM
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />Sarah Hinrichs, Hall Deputy County Attorney
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 17, 2014
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