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'4. To be completed by: CERTIFIER I I To be completed /verified by: FUNERAL DIRECTOR I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Roselle May Friesen 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) December 1, 2015 CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Henderson, Nebraska 5a. AGE - Last Birthday (Yrs.) 82 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) April 27, 1933 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -86 -0735 8a. PLACE OF DEATH HOSPITAL ❑ inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient EI Decedent's Home ❑ DOA ❑ Other (Specify) 8b. FACILITY -NAME (If not Institution, give street and number) 2012 N. Illinois Ave. 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 2012 N. Illinois Ave. 9e. APT. NO. 9f. ZIP CODE 68803 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 Don Robert Harvey 11. FATHER'S -NAME (First, Middle, Last, Suffix) Abraham Regier 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Elizabeth Braun 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Don Robert Harvey 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.} December 5, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Faith Evangelical Bible Church Cemetery Henderson 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) 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 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) Cardiomyopathy 2 Years disease or condition resulting n death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b) I any, leading to the cause listed � online 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 I 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Hypertension, Atrial Fibrillation 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® 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 0 N 21 d. 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 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE a to r E z 23a. DATE OF DEATH (Mo., Day, Yr.) December 1, 2015 F 0 8 ' _ E v o ` m z g C u ~ o o 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) 123c. December 3, 2015 TIME OF DEATH 11:30 PM _ 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD ' < 0 23d. To the best of my knowledge, death occurred at the time, date and place C a n d due to the cause(s) stated. (Signature and Title) Gary Settje, 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 Tide) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR ❑ YES SSUE DONATION BEEN CONSIDERED? 0 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Gary Settje, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 1 28 REGISTRAR'S SIGNATURE 4 - II �� a. { pV �� v 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 8, 2015 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH 4A RI(L ! AN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR4 KA QEIfARTMj 9 OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FORVITAAL- fR2ECO/Via: DATE OF ISSUANCE 12/11/2015 STATE OF NEBRASKA LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 201600088 S T A N L E Y S. COOPER ',. ASSIST' . TA P,EGIS ?RAR ND 15 07075