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To be completedNerified by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Nancy Lou Hardenberger 2. SEX : - ° 1, ', `,, Female 3 QA *E'OF DEATH (Mo., Day, Yr.) February 16, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Ainsworth, Nebraska 5a. AGE - Last Birthday (Yrs.) 47 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.) July 14, 1965 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505-90 -6705 8b. FACILITY -NAME (If not Institution, give street and number) 602 High Street 8a. PLACE OF DEATH (•IOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Cairo 68824 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Cairo 9d. STREET AND NUMBER 602 High Street e. APT. NO. r 9f. ZIP CODE 68824 9g. INSIDE CITY LIMITS 0 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 David Hardenberger 11. FATHER'S -NAME (First, Middle, Last, Suffix) Dick Osburn 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Louise Newland 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME David Hardenberger 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.) February 20, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Memorial Park Crematory Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livingston - Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 17b. Zip Code 68803 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 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 onset to death 3 Yrs 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) Malnutrition disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: ' onset to death Sequentially list conditions, If b) Metastatic Gastric Cancer 2 Yrs 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 but not resulting In the underlying cause given in PART I. Celiac Sprue 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 10 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 ® 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 B if, Y E IN z 23a. DATE OF DEATH (Mo., Day, Yr.) February 16, 2013 11 i i ). g. a. < 4 w 8 W 2 = '2 1 o 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b DATE SIGNED (Mo., Day, Yr.) February 19, 2013 23c. TIME OF DEATH I 08:43 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 0 3d. To the best of my knowledge, death occurred at the time, dab and place 2 and due to the pups) stated. (Signature and Title) O ` a Larry L. Hansen, 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 causes) 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 ONO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Larry L. Hansen, MD, 3016 West Faidley, Grand Island, Nebraska, 68803 1 28a. REGISTRAR'S SIGNATURE /lam � r 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I February 22, 2013 DATE OF ISSUANCE 02/28/2013 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HUTT Alfg I MA)V lERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRt 4 (]EPART=I%ENT (),HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FORITIF 0805 I4S : '•�',�� a0155 JS $4 7E GI Tt'A .DEPARTMENT OF HEALTH i4)VD LINCOLN, NEBRASKA I-I(f1t.4N` VICE . / i` ' `' STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER ICES,.' • • CERTIFICATE OF DEATH i!