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V 1.1% I 4 wI v V. v....-.. .. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Marilyn Marie Lif 2. SEX Female , 3. bATE OF DEATH (Mo.,Day,Yr.) December 26, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Alliance, Nebraska 5a. AGE -Last Birthday (Yrs.) 84 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) July 18, 1930 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -30 -9566 8a. PLACE OF DEATH HOSPITAL; ❑ Inpatient OTHER; ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home . ❑ DOA ®other(Specify)ASSISTED LIVING 8b. FACILITY -NAME (If not Institution, give street and number) Edgewood Vista Grand Island 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 1214 N. Howard Ave 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® Yes ❑ No 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated ® Widowed ❑ Divorced ❑ Unknown 1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Maynard Lif 11. FATHER'S -NAME (First, Middle, Last, Suffix) John H Ellis 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ruby Schutt 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) N 14a. INFORMANT -NAME Carrie Beacom 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ®Banal ['Donation ❑Cremation ['Entombment Removal ❑OMer(epecify) 16a. EMBALMER-SIGN RE �,f" 16b. LICENSE NO. /3,7 ' 16c. DATE (Mo., Day, Yr.) December 29, 2014 16d. CEMET RY, CRE ATORY OR OTHER LOCATION CITYITOWN STATE Westlawn Memorial Park Cemetery 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) te. PART I. Enter the chain of events - diseases, injuries, or complications- that directly caused the death. DO NOT enter terminal events such as cardiac attest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final disease or condition resulting a) ' , y f /f �+�nw in death) DUE TO, OR A CONSEQUENCE OF / // . Hz -is c • � onset to death Sequentially list conditions, If b) C /VAT " �` J e4,1-1--. any, leading to the a 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 onset to death the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONT TED? ❑ YES O 20. IF MALE: of 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. M ER OF DEATH ral ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY P WORMED? ❑ YES i 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES 1;t1D' 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) I 22d. INJURY AT WO K? 1 ❑ YES O 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE a° W ` d E o , u d o W 25. DID ❑ YES 23a. DATE OF DEATH ( o., Day, Yr.) /9 Z a 5 w d > IZ (4 } Q. a i it o n W Z c z p K V 24e. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH m 23b. DATE SIGNED (Mo., Day, Yr.) 1'l 23c. TIME OF DEATH 3 '13 Am 240. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD m 23d. To the bes y knowledge, death occurred at the time, data and place and due to a e(s state (Sign Lure and Title) 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) TOBACCO S �V NTRIBUTE TO THE DEA ? N. ■ PROBABLY ❑ U NOWN 26a. HAS ORGAN OR TISSUE NATION BEEN CONSIDERED? ❑ YES NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES NO 27. NAME, TITLE AN • • DDRESS OF CERTIFIER (Type or Print) N. ( \phn \Nagonef TS( N. NOI. -St. i■r,\,nrl ISlQM N. i ,3 28a. REGISTRAR'S SIGNATURE 1 .. ,Q. t ' 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) JAN 7 2014 re W Ii w U WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH' N r ERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAS A,DEPA1 l T OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR, VITAL •RECORDS.. DATE OF ISSUANCE JAN 0 7 2015 LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA 201501845 STAN Y S COOPER A.SI T St ATt REGATRtiR b � E PA. 1 CF EALT .k1UMAN SERVICES 7