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4 R ♦ i. t .;Mi (d a., t .MI STATE OF NEBRASKA , :. t _ m om ,.. WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT 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 DATE OP ISSUANCE 04/07/2016 LINCOLN, NEBRASKA 201602208 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Coe STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 16 01784 3. DATE OF DEATH (Mo., Day, Yr.) March 31, 2016 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Ethel Bernice Bonsack 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Hall County, Nebraska 7. SOCIAL SECURITY NUMBER 506 -22 -6860 . FACILITY -NAME (If riot Institution, give street and number) Tiffany Square •Care :Center 8c. CITY OR TOWN OF DEATH (Include'ip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 3119 West Faidley Avenue 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, bUt separated ® Widowed ❑ Divorced ❑ Unknown Orville Conn 13, EVER IN U.S: ARMEDF.ORCES? Give dates of service if Yes. (Yes, No, pr Unk.) NO 16. M OF DISPOStTIE)N ❑ Burial ,0 Donation ® Cremation ❑ Entombment ❑ Removal ?❑ Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska eguemialty list conditia any leading to the lcause>li on line a ". DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) • (disease. ot inturY that initlate t • the events tesoldng 4 "th ) DUE TO, OR AS A CONSEQUENCE OF: LAST. >I d) 0. IFFEMALE; ❑ Not pregnantwkhinpast year ❑ Pregnant at time of death ❑ Not pregnant,;but pregnant within 42 days of death ❑ Rot pre(Inanti: but pregnant 43 days to 1 year before death ❑ Unknown If pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) t2d. (NJt)RY AT WORK? ': IJ YES J NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. f a. DATE OF DEATH (Mo., Day, Yr.) March 31, 2016 3b. D tTE SIoED (Mo., Day, Yr.) April 1, 2016 22b. TIME OF INJURY 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) •Steven Husen, MD 1 28a. REGISTRARS SIGNATURE 23c. TIME OF DEATH 01 :55 PM 5a. AGE - Last Birthday (Yrs.) 89 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Not Embalmed 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Gould not be determined CITY /TOWN 5b. UNDER .1 YEAR MOS. Ruth VanWinkle DAYS 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA OTHER ® Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) Hospice Facility 9c. CITY OR TOWN Grand ,Island 9e. APT. NO. 10b. NAME OF SPOLISE (First, Middle, Last, Suffix) If wife, give maiden name LaVern Bonsack 1. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname) 14a. INFORMANT -NAME Dennis Bonsack 16b.LICENSE NO. CAUSE OF DEATH (See instructions and examples) PART I Enter the chain At events -- diseases, injuries, or complications -that directly caused the death, DO NOT enter terminal events such as cardiac arrest, respiratory arrest; or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a 000. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Chronic Respiratory Failure With Hypoxia And Hypercapnia disease or condition resulting in. death) DUE TO, OR AS A CONSEQUENCE OF: b) End Stage Chronic Obstructive Pulmonary Disease With 8ronchiectasis, Chronic Bronchitis 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Chronic Diastolic Congestive Heart Failure, Type II Diabetes, Hypertension 8d. COUNTY OF DEATH Hall 21b, IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian Other (Specify) STATE 24a. DATE SIGNED (Mo., Day, Yr.) RONOUNCED DEAD (Mo., Day, Yr.) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES El NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 9f. ZIP CODE 68803 December 17, 1 6. DATE OF BIRTH (Mo Da 926 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Son 16c. DATE (Mo., Day, Yr.) April 1, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon STATE Nebraska" 17b, Zip: Code 68601 AP PROXIMATEINTERVAL onset to death About 1 Year onset to death i' >10 Years onset to death I onset to death:" I _ 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE QF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED ZIP CODE 24b. TIME OF DEATH 24d, TIME PRONOUNCED DEAD E ▪ - w z O 24e. On the basis of examination and /or investigation, in my opinion death occurred at Z u the time, date and place and due to the cause(s) stated. (Signature and Title) o 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES © NO 28b. DATE FILED BY REGISTRAR (MO<, Day, Yr.) April 4, 2016