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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Deanna Ray Berg 2. SEX ' / Female= , 3. DATE OF,ISEATH (Mo., Day, Yr.) September 7, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 72 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6, DATE OF BIRTH (Mo., Day, Yr.) July 22, 1943 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -50 -7609 8b. FACILITY -NAME (If not Institution, give street and number) Golden LivingCenter -Grand Island Lakeview 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 1522 South Gunbarrel Road 9e. 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 Donald Berg 11. FATHER'S -NAME (First, Middle, Last, Suffix) Thomas Myers 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ella Jane Reid 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Donald Berg 14b. RELATIONSHIP TO DECEDENT Spouse 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.) September 8, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING 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) 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 Months 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) Widely metastatic carcinoma likely of Pancreatic Origin disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: l onset to death Sequentially list conditions, it b) 1 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) 1 (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 1 8. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART 1. Ovarian Mass, Hypertension, Splenic Infarct 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 0. 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 ❑ Pe Investigation ❑ suicide ❑ Could not be detemtined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) September 7, 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.) September 8, 2015 23c. TIME OF DEATH 01:30 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title( Jay C. Anderson, MD 24., On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cau e(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 0 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 8803 1 28a, REGISTRAR'S SIGNATURE - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) September 11, 2015 STATE OF NEBRASKA 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 NEBRASKA•bEPP1R7 4 OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR A/77414 RECORDS. 1 SAANLEY S..COQPER. , / ASSIST ,TATE REGIST,&A, T Olt HfALTH AND' DATE OF ISSUANCE 09/15/2015 LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH ' 201508761 15 05248