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To be completed /verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Beverly Lou McDermott I. SEX . Fen3*, ` ,3, DATE OF DEATH (Mo., Day, Yr.) , August 21, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Cotesfield, Nebraska 5a. AGE - Last Birthday (Yrs.) 77 5b. UNDER 1 YEAR 5cUNDEFt1 `DAY 6, DATE OF BIRTH (Mo., Day, Yr.) March 20, 1938 MOS. DAYS HOURS , MINS. 7. SOCIAL SECURITY NUMBER 506 -42 -4245 8b. FACILITY -NAME (If not Institution, give street and number) Good Samaritan Society -Grand Island Village 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 4055 Timberline St 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS M YES ❑ NO 10a, MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Joseph Eugene McDermott 11. FATHER'S -NAME (First, Middle, Last, Suffix) Morris Anderson 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Edna Nielsen 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Joseph Eugene McDermott 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Patricia R. Curran 16b. LICENSE NO. 1092 16c. DATE (Mo., Day, Yr.) August 25, 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) • Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska 17b. Zip Code 68801 Li To be completed by: CERTIFIER 1 1 CAUSE OF DEATH (See instructions and examples) 11. 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 3 Years respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Tine. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Stage IV Ovarian Cancer,with Metastatic Disease disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death Sequentially list conditions, if b) I any, leading to the cause listed I 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: ; 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: I onset to death LAST d) i 1 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Small Bowel Obstruction, Pulmonary Embolism, Hypertension, History Of Incer, Kidney Cancer 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: ❑ Not pregnant within past year 0 Pregnant at time of death 0 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 21 MANNER OF DE IGI Natural ❑ Homicide ❑ Accident 0 Pen Ition Suicide Cou 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? 0 YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED , 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE E W i rc } E U i 23a. DATE OF DEATH (Mo., Day, Yr.) August 21, 2015 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.) August 24, 2015 23c. TIME OF DEATH 05:20 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD g u 0 3d. To the best of my knowledge, death occurred at the time, date and place G and due to the cause(s) stated. (Signature and Title) ~ Jane A. McDonald, 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 TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803 • 128a. REGISTRAR'S SIGNATURE J 6 ' � u - - p � V 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) l August 27, 2015 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 NEBRASKAPERAK ENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FAR VITAL I E O! D DATE OF ISSUANCE 08/31/2015 LINCOLN, NEB STATE OF NEBRASKA STANLEY °S COOPER r 5 ASSISTANT STATE REGISTRAnt RASKA 201508365 'F4 SERVICES OEALTH;AND.; STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN gERVjCgS CERTIFICATE OF DEATH 1 04972