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To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Cathy Lynn Bredthauer 2. SEX ' '- Femal 3. fkATE F 10EATPr Mo., Day, Yr.) Atlga) 24..`261.4,- 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 66 5b. UNDER 1 YEAR 5c. UNDER 1 DAY .'18 i3ATE OF BIRTH (Molt'Day, Yr.) April 7, 1948 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -66 -0948 8b. FACILITY -NAME (If not Institution, give street and number) St. Francis Memorial Health Center LTC 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 1912 Stolley Park Cir APT. NO. 1 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS IN 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 Dale Bredthauer 11. FATHER'S -NAME (First, Middle, Last, Suffix) Harold Barge 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Elsie Rothfuss 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Larry Dale Bredthauer 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation IX) Cremation 0 Entombment ❑ Removal 0 Other (Specify) 16a. EMBALMER - SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) August 22, 2014 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 I 18. PART I. Enter the chain of events - diseases, Injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death 2001 -Death 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) Ovarian Cancer - Malignant disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death Sequentially list conditions, If b) I any, leading to the cause listed 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: I onset to death Enter the UNDERLYING CAUSE c ) I (disease or Injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) I I 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 ID Natural ❑ Homicide 0 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 'II' Y rc r E ui 23a. IMTE OF DEEA= (Mo., Day, Yr.) August 20, 2014 124a. ,; ' r E da g W z B 0 0 ~ o a DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) August 21,2014 I 23c. TIME OF DEATH 11:55 PM 24c. PRONOUNCED DEAD (MO., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3 < O 3d. To the best of my knowledge, death occurred at the time, date and place .g a and due to the cause(s) stated. (Signature and Title) o '' 2 Richard Fruehling, 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 cau e(6) stated. (Signature and Title) 26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 28b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) August 22, 2014 1 28a STATE OF NEBRASKA 201504'135 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN 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 VVIT4L - RE DATE OF ISSUANCE 08/25/201 4 LINCOLN, NEB STANLE� V,e00 AS,0"I A11?T.9'TATE RE�IITRAR Nr., ©Evegl r Qr EALTH `AND NEBRASKA Hotly' SEIM STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERIOU CERTIFICATE OF DEATH 14 04204