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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Evelyn Mae Weatherly 2. SEX Female '3: DkTaOe`DEATH (Mo., Day, Yr.) June'1, 2011 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Broken Bow, Nebraska 5a. AGE - Last Birthday (Yrs.) 83 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) February 28, 1928 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -26 -7178 8b. FACILITY -NAME (H not Institution, give street and number) Tiffany Square Care Center 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 2604 W Koenig St e. APT. NO. 9f. ZIP CODE 68801 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, Suffix) If wife, give maiden name John Francis Weatherly 11. FATHER'S -NAME (First, Middle, Last, Suffix) John Piper 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Lila Spencer 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME John Weatherly 14b. RELATIONSHIP TO DECEDENT Husband 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.) June 4, 2011 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon 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) To be completed by: CERTIFIER 18. 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 1 Month 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) Papillary Carcinoma With- Abdominal Metastases And Ascites disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Possible Ovarian Cancer Vs Primary Peritoneal Cancer 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 d but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES IJ 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 ermined ❑ ❑ 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 0 N 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 I F 2 re E u z 23a. DATE OF DEATH (Mo., Day, Yr.) June 1, 2011 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) June 6, 2011 23c. TIME OF DEATH 07:40 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 g 0 3d. To the best of my knowledge, death occurred at the time, date and place Z G and due to the cause(s) stated. (Signature and Title) g 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 cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TI SUE r • ❑ YES I:gi NO ATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, Richard Fruehling, MD, 2116 W Faidley #400, HYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY A Box 9802, Grand Island, Nebraska, 68803 ORNEY) (Type or Print) 128a REGISTRAR'S SIGNATURE / A f /� _ . t1`� j JR Y( L_�OJOJYQ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I June 13, 2011 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT QF HEALTH+AND HUMA, SIgRrVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA Q bARTM,ENT QF i IEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR 1IT 6It. FEN Ijo ; I DATE OF ISSUANCE 06/13/2011 LINCOLN, NEBRASKA 20. p STAAILEY Q0QPER ,; ; 1 AS;§1�;Ti9NT AfE t R si1 usa7 - : : DEPARTMENT OF HEALr AWD HUMAN >55ER tt'1 ES ` STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVIGES >, r • CERTIFICATE OF DEATH 11 01976