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To be completed/verified by: FUNERAL DIRECTOR ' 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Diane Lynn Collins 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) Octpber19, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Central City, Nebraska 5a. AGE - Last Birthday (Yrs.) 54 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) - April 25, 1961 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -90 -8850 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 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 2524 N. North Rd 9e. APT. NO. 9f. ZIP CODE I 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 Ellis Keith Collins 11. FATHER'S -NAME (First, Middle, Last, Suffix) Donald Eugene Hansen 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Nancy Joan Sorensen 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or link.) No 14a. INFORMANT -NAME Ellis Keith Collins 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Leslie M. Solt 16b. LICENSE NO. 1398 16c. DATE (Mo., Day, Yr.) October 22, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central City Cemetery Central City Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Solt- Wagner Funeral Home, 1507 17th Street, Central City, Nebraska 17b. Zip Code 68826 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 16. 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 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) Metastatic Cancer disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death Sequentially list conditions, if b) Pancreatic Carcinoma I 2/24/2015 any, leading to the cause listed I I on line a. DUE TO, OR AS A CONSEQUENCE OF: l 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: 1 onset to death LAST d) 1 1 1 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death . . not resulting In the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 13 NO ). 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 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? ❑ YES 0 N 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.) October 19, 2015 To be completed by CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) October 20, 2015 23c. TIME OF DEATH 10:35 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 2d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) John Wilcox, MD 24e. On the basis of examination and/or Investig tion, 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 ❑ YES ISSUE • a ATION BEEN CONSIDERED? 17 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERT(FIIER1Type or Print John Wilcox, MD, 609 O Street, Aurora, Nebraska, 68818 128a. REGISTRAR'S SIGNATURE J I � � �� _ •O -Y 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 20, 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 DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. IS 4 DATE OF ISSUANCE 201600589 STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND LINCOLN, NEBRASKA HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES. - CERTIFICATE OF DEATH 10/20/2015