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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND H t4 SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINA4AECOR THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE NOV Q 8 2007 , � tET 9' ) LINCOLN, NEBRASKA EAi1 "A ID HUMAN $#14C STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN t11/1OLS F1N ANDS RT CERTIFICATE OF DEATH 'r i 3 . . 201508095 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) ! ., Beverly Joan Ostrander 2. EX ren. 1e ., 3.DAT"E,QFDEATH (Mo., Day, Yr.) ' October 25, 2007 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Central City, Nebraska 5a. AGE -Last Birthday (Yrs.) 73 5b. UNDER 1 YEAR So..UNDEt4til- r3A`f -' 6. DATE OF BIRTH (Mo., Day. Yr.) June 7, 1934 MOS. DAYS HOURS M'INS. 7. SOCIAL SECURITY NUMBER 507 -36 -1464 8a. PLACE OF DEATH HOSPITAL: ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) 315 N. Washington St. ❑ ERlOuptatlent ®DecedenrsHome ❑ IDa ❑ Other(Specify) To Be Completed/Verified by: FUNERAL DU 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH 'Hall ga. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9a CITY OR TOWN Grand Island 9d. STREET AND NUMBER 315 N. Washington St. 9e. APT. NO 91. ZIP CODE 68801 9g. INSIDE CITY LIMITS 51 YES ❑ NO 10a, MARITAL STATUS AT TIME OF DEATH El Married ❑ Never Marned ❑ Marned, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First. Middle, Last, Suffix) If wife, give maiden name. Donald Ostrander 11. FATHER'S-NAME (First, Middle, Last, Suffix) Leslie William Martin 12. MOTHER'S -NAME (First, Middle, Malden Surname) Nina Grace Dughman 13. EVER IN U.S. ARMED FORCES? Give dates of service If yes. (Yes, no, orunk.) No 14a. INFORMANT -NAME Donald Ostrander 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION ® Burial ❑Donation ❑ Cremation ❑Entombment ❑ Removal ❑ Other (Specify) 16a. BALMER•SIGNA7y 4 7 77 ,- 16b. LICENSE NO. / d 7/ 16c. DATE (Mo., Day, Yr. ) October 30, 2007 ..2) 16d. CEMETERY, CREMATORY OR OTHER LOCA N CITYITOWN STATE Westlawn Memorial Park Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAIL NO ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, N ebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions lei '- -' 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 ../Ch ; a•J,ac arrest, AF *ROXIM: =.- c .- ;AL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a IIne.Add additional lines If necessary. IMMEDIATE CAUSE: onset to death ) ` J n IMMEDIATECAUSE(FInal a ` C Z n pp , s t^ W'A'R k dbeasa orcondttbnruuttlrg DUE TO, OR AS A CON ENCE OR I onset to death C In death) Sequentially list conditions, d 04 arty, leading 10 NM" listed DUE TO, 011 AS A CONSEQUENOE 0F: 1 onset to death on line a. Enter the UNDERLYINGCAUSE (disease or Injury that Initiated (0) the events resulting In death) DUE TO. 011 AS A CONSEQUENCE OF: I onset to death IAST (d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. ^ C Q a 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ig 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 yearbelore death ❑ Unknown 11 pregnant within the past year 21a. MANNER OF DEATH aNrel 0 Homicide ❑ Accident❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑Ddver/Operetor ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? CI YES �NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY M 220. PLACE OF INJURY -At home, farm, street, factory, office building, constructlo 22d. INJURY ATWORK? ❑ YES ❑ NO 22e. DESCRIBE HOW tNJURY 000URRED INOV 3 0 2007 221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE CL To be completed by Attending PHYSICIAN ONLY 23a. DATE OF DEATH (MO., Day, Yr.) I 0 "as- o _ a0a 24a. DATE SIGNED (Mo., Day,Yr.) 24b.TIME OF DEATH m 23b. DATE SIGNED (Mo., Day, Yr.) O 23c. 11ME OF DEATH 'a S'O m N _ ad<ti E!>z 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD m 23d. To the best of my knowledge, death occurred at the time, date and place 8 f z 0 24e. On the basis of examination and/or invesligation, In my opinion death occurred at �ud.Q to the cause(s stated. (Signature and Title) • o ¢ 8 the time, date and place and due to the cause(s) stated. (Signature and Title) • Jr) \?‘( f\ 1_24N 1_24N \ \ 1L MO ~ 8 s 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY UN KNOWN 26a. HAS ORGAN OR TISSUE ( DONATION BEEN CONSIDERED? ❑ YES SILO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type orPnnt) John Cannella, M.D., 729 N. Custer, Grand Island, NE 68803 28a. REGISTRAR'S SIGNATURE il 1 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) NOV 5 2007 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND H t4 SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINA4AECOR THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE NOV Q 8 2007 , � tET 9' ) LINCOLN, NEBRASKA EAi1 "A ID HUMAN $#14C STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN t11/1OLS F1N ANDS RT CERTIFICATE OF DEATH 'r i 3 . . 201508095