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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Lisa Kim Sterling 2. SEX^ i / ` : Female' 1 . '. {. '3. OE DEATH (Mo., Day, Yr.) % Retrru'ary 24, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Fort Wayne, Indiana 5a. AGE - Last Birthday (Yrs.) 59 5b. UNDER 1 YEAR 5c. UNDER 1. DAY 6. DATE OF BIRTH (Mo., Day, Yr.) August 29, 1955 MOS. DAYS HOURS MINS.'` 7. SOCIAL SECURITY NUMBER 313 -66 -7106 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 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 322 N. Ruby Avenue e. APT. NO. r 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS M YES ❑ NO 105. 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 11. FATHER'S -NAME (First, Middle, Last, Suffix) John Henry Sterling 12. MOTHER'S -NAME (First, Middle, Malden Surname) Gloria Deal 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Danielle Brown 14b. RELATIONSHIP TO DECEDENT Daughter 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 27, 2015 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) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER it. 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 36 Hrs 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) Septic Shock disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b) Sepsis I 36 Hrs any, leading to the cause listed I 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: i onset to death Enter the UNDERLYING CAUSE c) Ischemic Bowel 1 3 Days (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LAST d) 1 t 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Chronic Obstructive Pulmonary Disease, Type II Diabetes, Inflammatory Bowel Disease 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE: ® Not pregnant within past year ❑ Pregnant a time o f 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 INJUR`/j21c. ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) WAS AN AUTOPSY PERFORMED? I ❑ YES ID 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 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE a W F E z 23a. DATE OF DEATH (Mo., Day, Yr.) February 24, 2015 2 1 i. 1 E 2 4< I r, g 0 Z 8 Z p a 0 ' 0 5 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) February 26 , 2015 23c. TIME OF DEATH I 02 PM 24e. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD ° u O e < 23d. To the best of my knowledge, death occurred at the time, date and place 2 W and due to the cause(s) stated. (Signature nd Title) 0 0 2 Steven Husen, 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 cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN I26a. HAS ORGAN OR DONATION BEEN CONSIDERED? ❑ YES gl NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Punt Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE A (�� DATE FILED BY REGISTRAR (Mo., Day, Yr.) 28 b. March 2, 2015 DATE OF ISSUANCE 03/06/2015 LINCOLN, NEBRASKA 2 015 . 01846 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH., ND414/MAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA pEPAR,TMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY For Vpi L j ECQRD5 Q STANLEY S COOPER. /' . - ASSISTi?VT gTATE REGIS7TRAR DEPARTMENT 6JFWEALTH AN L ,l HUMAN SERVICES r' STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVES < . a • ' CERTIFICATE OF DEATH " Y` • • . 15 01199