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17. To be completed by: CERTIFIER 1 1 To be completed /verified by: FUNERAL DIRECTOR 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Lola Jan Marshall 2. SEX ^ ' 1 ' Female " ":' 3. DATE OF DEATH (Mo., Day, Yr.) , h 1, 2015 " Ma 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Columbus, Mississippi 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY - 6. DATE OF BIRTH (Mo., Day, Yr.) October 1, 1944 (Yrs.) 70 MOS. DAYS HOURS MINS. SOCIAL SECURITY NUMBER 507 -56 -0274 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient QTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Home ❑ DOA ❑ Other (Specify) 8b. FACILITY -NAME (If not Institution, give street and number) 2416 Cottonwood Road 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2416 Cottonwood Road 9e. APT. NO. 19f. ZIP CODE 68801 9g. INSIDE CITY LIMITS M 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 Larry Joe Marshall 11. FATHER'S -NAME (First, Middle, Last, Suffix) John Martindale 12. MOTHER'S -NAME (First, Middle, Maiden Sumame) Lola Young 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Larry Joe Marshall 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) March 5, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING 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) 18. PART 1. 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) Respiratory Failure disease or condition resulting onset to death 2 Days in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, it b) Multiple Sclerosis 1 30 Years any, leading to the cause listed 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) 1 (disease or Injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST 1 d) 1 1 18. PART 11. 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 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 ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide El 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? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE o 6 &1 '' r E u z 23a. DATE OF DEATH (Mo., Day, Yr.) March 1, 2015 B g 1 ° k o La c " W 2 8 G u ' o s 24a. DATE SIGNED (Mo., Day, Yr.) _ 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) Marc 3, 2015 23c. TIME OF DEATH 09:30 AM S a Q 3d. To Inc best of my knowledge, death occurred at the time, date and place 8 G and due to Inc cause(s) stated. (Signature and Title) ' - a William Landis, MO 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 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print William Landis, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE - ! '_- 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) March 4, 2015 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND. HL{MAA' SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL, RECORDS, , DATE OF ISSUANCE 03/10/2015 201503613 STANLEY S. COOPER c , 1 f ASSIS};Xlry1V ., TATE REGIS 'I AIR DEPARTMENT HEALTH ANd LINCOLN, NEBRASKA - Pii.V IAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVkCRS !^ f CERTIFICATE OF DEATH 15 01257