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To be completed/verified by: FUNERAL DIRECTOR I
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Virginia Mae Humiston
<br />2. SEX,' a k ; , ' ,
<br />Female'u�.
<br />I4 FZOF NEpttH (M�o. Bay, Yr.)
<br />• . IAy.'2 2Ri ' :'
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Giltner, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />86
<br />5b. UNDER 1 YEAR
<br />5c. UNDEI 1FD ►Y:
<br />t5LDATE OF XMMo,,pay, Yr.)
<br />a "'
<br />October 8,1'926
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS!:
<br />7. SOCIAL SECURITY NUMBER
<br />506 -26 -2206
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Saint Francis Medical Center
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility
<br />❑ ER/Outpatient ❑ Decedent's Home - -
<br />❑ DOA ❑ Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />2403 W. Koenig Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803 .
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married
<br />❑ Married, but separated ® Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Robert M Humiston
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />William Jankovitz
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Viola Vance
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or link.) No
<br />14a. INFORMANT -NAME
<br />Dee Garrett
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. EMBALMER - SIGNATURE
<br />Tracey Dietz
<br />16b. LICENSE NO.
<br />1328
<br />16c. DATE (Mo., Day, Yr.)
<br />May 28, 2013
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlawn Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. Zlp Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />1 To be completed by: CERTIFIER
<br />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,
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />1 Month
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Aspiration Pneumonia
<br />disease or condition resulting
<br />in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Sequentially list conditions, if b) Metastatic Adenocarcinoma Of The Breast > 1 Year
<br />any, leading to the cause listed
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or Injury that initiated
<br />the events resulting to death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES 0 N
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />2. 5
<br />1
<br />E 2 '
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May24,2013
<br />Y
<br />2'il
<br />1 i k
<br />E a. < 4
<br />y
<br />$ W �
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<br />~ 0 a
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />May 24, 2013
<br />23c. TIME OF DEATH
<br />08:45 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />v < 0 3d. To the best of my knowledge, death occurred at the time, date and place
<br />8 c and due to the cause(s) stated. (Signature and Title)
<br />o
<br />a Jennifer L. Brown, MD
<br />24e On the basis of examination and/or investigation, In my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />Z. DID Tt reAL WIS1liibUf e c THE - O ATiif tea. PtA6 Wiit3AN OR ilS&UE DONATION tsEEN CONSIDEI ED
<br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ Y ES ® NO
<br />2s'b. WAS CONSENT GRAr7TE7V -' - - -
<br />Not Applicable If 26a Is NO 0 YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE ®� a
<br />28b. DATE FILED BY REGISTRAR ( Mo., D Yr.)
<br />May 28, 2013
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HE/y0:.H ANI
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECOR'DD•
<br />DATE OF ISSUANCE
<br />05/31/2013
<br />STATE OF NEBRASKA
<br />CERTIFICATE OF DEATH
<br />201601.146 STAI)fLEY ? ...COOPER: • . •
<br />ASSIST v.T STATE REOIS"'fR I
<br />DEPAi2TN1ENT OrtHEALTH'A
<br />LINCOLN, NEBRASKA HUMi9N :SERf'7CE,S
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES; �" a p
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