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To be completed by: CERTIFIER I I To be completed /verified by: FUNERAL DIRECTOR I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Maxine Imogene Lowry 2. SEX Female 43. DATE OF DEATH (Mo., Day, Yr.) January 28, 2016 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Loup City, Nebraska 5a. AGE - Last Birthday (Yrs.) 84 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) October 14, 1931 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -30 -2726 8b. FACILITY -NAME (If not Institution, give street and number) 1142 S. Vine St. 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 1142 S. Vine St. 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS M 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 Philip Dean Lowry 11. FATHER'S -NAME (First, Middle, Last, Suffix) Frank Waskowiak 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Anna Galus 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Christi Sue Williams 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DiSPUSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) January 30, 2016 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) 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: IMMEDIATE CAUSE (Final a) Myelodysplastic Syndrome, Aggressive, Pancytopenia disease or condition resulting onset to death Less Than 1 Week in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (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. Severe Degenerative Arthritis, History Of Breast Cancer, Depression, Hypertension 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ P regnant 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 IE Natural ❑ Homicide ❑Accident ❑ Pending Investigation El Suicide ❑ Could determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator Passenger ❑Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑YES El NO 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 ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET S NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 2 W i I E t z 23a. DATE OF DEATH (Mo., Day, Yr.) January 28, 2016 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.) January 29, 2016 23c. TIME OF DEATH 10:23 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD g � 0 2 3d. To the best of my knowledge, death occurred at the time, date and place 5 and due to the cause(s) stated. (Signature nd Title) o 2 Jane A. McDonald, MD 24e. On the basis of examination andlor 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? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 17 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, 43 128 REGISTRAR'S SIGNATURE - g. J 28 b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) February 1, 2016 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH A (((MAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA T 'DE FJ'J,T OF HEALTH AND FOR VI HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOTA11.14Eb DATE OF ISSUANCE 02/03/2016 STATE OF NEBRASKA S#ANLEY S O G P E R e'° ASSISTTNT•STATE REGIS"T Ai DePART.LENI "Op`l-1B,4LTH;AND LINCOLN, NEBRASKA 'HUMAN SERVICES, STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES' CERTIFICATE OF DEATH 101601848 16 00472