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To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Janice Marie Thayer 2 SEX' "4 k , "` Female " 3:'OATE OF DEATH (Mo., Day, Yr.) ' -May 3, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 76 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) June 18, 1937 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506-44 -1105 8b. FACILITY -NAME (If not Institution, give street and number) 2307 Stagecoach Road 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 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2307 Stagecoach Road 9e. APT. NO. 9f. 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 Ernest James Thayer 11. FATHER'S -NAME (First, Middle, Last, Suffix) Alfred Larson 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Evelyn Andrews 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Ernest James Thayer 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) May 8, 2014 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 To be completed by: CERTIFIER I I CAUSE OF DEATH (See instructions and examples) 19. 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: onset to death IMMEDIATE CAUSE (Final a) Adenocarcinoma Of Lung With Mets To Brain, Pleural Fluid, Bone And Pericardial Fluid 2 Years disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) any, leading to the 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 the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: Onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given In PART I. Hypertension, Osteopenia, Kyphosis 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El 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 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 W LT. E � i 23a. DATE OF DEATH (Mo., Day, Yr.) May 3, 2014 Y b' , z _ F. a $ w z O 8 & p ~ r) s 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) May 13, 2014 23c. TIME OF DEATH I 11:51 PM 24c. PRONOUNCED DEAD (MO., Day, Yr.) 24d. TIME PRONOUNCED DEAD ° u 0 9d. To the best of my knowledge, death occurred at the time, date and plea .3 c and due to the cause(s) stated. (Signature and Title) 2 Kimberly A. Mickels, 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? 26a. HAS ORGAN OR ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑YES r • ATION BEEN CONSIDERED? 17 a 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO 0 YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island Nebraska, 68803 28a. REGISTRAR'S SIGNATURE /L. / /� �- V�pw 28b. DATE FILED BY REGISTRAR (Mo, Day, Yr.) I May 13, 2014 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND' HUMA/V SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DkPAR,TMEN o OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL- RF, RL)S. DATE OF ISSUANCE 2015060'77 05/16/2014 SSIS1AN 57 T tREGIS7 D,EPARTMEN"r bf HEALTH AND LINCOLN, NEBRASKA HUNIN,SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S'ER)ABE3 CERTIFICATE OF DEATH r a `' " , 14 02321