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To be completed by: CERTIFIER To be completed/verified by: FUNERAL DIRECTOR I 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Margaret Leone Bellairs 2. SEX Female 3 DATE OF DEATH (Mo., Day, Yr.) June 30, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH O'Connor, Nebraska 5a. AGE - Last Birthday (Yrs.) 91 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) October 7, 1923 MOS. DAYS HOURS INS. 7. SOCIAL SECURITY NUMBER 506-26 -0427 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health Nebraska Heart 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ ursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ ecedent's Home ❑ DOA ❑ ther (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Lincoln 68526 8d. COUNTY OF D Lancaster TH 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2520 West Koenig Street 9e. APT. NO. 9f. ZIP ODE 688 3 9g. INSIDE CITY LIMITS ® 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, Suffl ) If wife, give maiden name Gerald Edward Bellairs 11. FATHER'S -NAME (First, Middle, Last, Suffix) John Burns 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Anna Mulcahy 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME George E Bellairs 14b. RELATIONSHIP TO DECEDENT Son 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal 0 Other (specify) 16a. EMBALMER - SIGNATURE L. Todd Biester 16b. LICENSE NO. 1152 16c. DATE (Mo., Day, Yr.) July 6, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 10. 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 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) Cardiogenic Shock disease or condition resulting onset to death '. 3 Days in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b) Coronary Artery Disease 1 Years any, leading to the cause listed 1 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 1 the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) 1 t 1 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given In PART 1. Valvular Heart Disease, Cardiomyopathy 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 0 Pending investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJUR ❑ Driver /Operator Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO ❑ Pedestrian ❑ Other (specify) 21d. WERE AUTOPSY FINDINGS AVAILABL 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 bull ing, 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 I' W i rc T o !I, z 23a. DATE OF DEATH (Mo., Day, Yr.) June 30, 2015 1. s z I i , o w < o u W 2 E i O ~ $ o 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) Jul 2, 2015 23c. TIME OF DEATH 06:59 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD u a 0 d. To the best of my knowledge, death occurred at the time, date and place b' c2 and due to the causes) stated. (Signature and Title) Hosakote M. Nagaraj, MD 24e. On the basis of examination and/or Inv the time, date and place and due to th stlgation, in my opinion death occurred at cau e(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. S CONSENT GRANTED? Not Ap livable If 26a Is NO ❑YES El NO 27. NAME, TITLE AND ADDRESS OF CER IFTER Type orPrint Hosakote M. Nagaraj, MD, 7440 S 91st St, Lincoln, Nebraska, 68526 r REGISTRAR'S SIGNATURE 28b. DA FILED BY REGISTRAR (Mo., Day, Yr.) July 7; 2015 I 128a. DATE OF ISSUANCE 07/09/2015 LINCOLN, NEBRASKA STATE OF NEBRASKA 201505413 ! k '' 4 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERI CERTIFICATE OF DEATH WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF hE4 It/Cd IYe1lx THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE SK ; HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY F�,�' ,,VI Sc# VECES, IT CERTIFIES F HEALTH AND ,e '0- /