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To be completed by: CERTIFIER 1 1 To be completed /verified by: FUNERAL DIRECTOR <br />1. DECEDENTS -NAME (First, Middle, Last, Suffix) <br />Esther Catherine Luhn <br />2. SEX ' , ' ' / " ; <br />Female; <br />'COATE"QF 17EATH (Mo., Day, Yr.) <br />',October 15, 2015 <br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH <br />Grand Island, Nebraska <br />5a. AGE - Last Birthday <br />(Yrs.) <br />94 <br />5b. UNDER 1 YEAR <br />5c. UNDER 1 DAY ` <br />6. DATE OF BIRTH (Mo., Day, Yr.) <br />June 21, 1921 <br />MOS. <br />DAYS <br />HOURS <br />MINS. <br />7. SOCIAL SECURITY NUMBER <br />506 -22 -4148 <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 />8b. FACILITY -NAME (If not Institution, give street and number) <br />Good Samaritan Society -Wood River <br />8c. CITY OR TOWN OF DEATH (Include Zip Code) <br />Wood River 68883 <br />8d. COUNTY OF DEATH <br />Hall <br />9a. RESIDENCE -STATE <br />Nebraska <br />9b. COUNTY <br />Hall <br />9c. CITY OR TOWN <br />Wood River <br />9d. STREET AND NUMBER <br />1401 East Street <br />9e. APT. NO. <br />9f. ZIP CODE <br />68883 <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 />LaVern Luhn <br />11. FATHER'S -NAME (First, Middle, Last, Suffix) <br />Carl T Harris <br />12. MOTHER'S -NAME (First, Middle, Maiden Sumame) <br />Tina Schlieker <br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. <br />(Yes, No, or Unk.) No <br />14a. INFORMANT -NAME <br />Gary Luhn <br />14b. RELATIONSHIP TO DECEDENT <br />Son <br />15. METHOD OF DISPOSITION <br />❑ Burial ❑ Donation <br />® Cremation ❑Entombment <br />❑ Removal ❑ Other (Specify) <br />16a. EMBALMER - SIGNATURE <br />Not Embalmed <br />16b. LICENSE NO. <br />16c. DATE (Me., Day, Yr.) <br />October 16, 2015 <br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE <br />Central Nebraska Cremation Services Gibbon Nebraska <br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) <br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska <br />17b. Zip Code <br />68801 <br />CAUSE OF DEATH (See instructions and examples) <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 />Weeks <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) Pneumonia - NOS <br />disease or condition resulting <br />in death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death <br />Sequentially list conditions, if b) Vascular Congestion - Lungs And Lower Extremeties 1 Weeks <br />any, leading to the cause listed 1 <br />1 <br />on line a. DUE TO, OR AS A CONSEQUENCE OF: i onset to death <br />Enter the UNDERLYING CAUSE c) 1 <br />(disease or injury that initiated <br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death <br />LAST 1 <br />d) 1 <br />1 <br />18. PART I I . OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death ' ' not resulting in the underlying cause given In PART I. <br />Diabetes, Hypertension, Dementia With Psychosis, Glaucoma <br />19. WAS MEDICAL EXAMINER <br />OR CORONER CONTACTED? <br />❑ YES ® NO <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 P1 investigation <br />❑ ❑ <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 8. NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE <br />a W <br />i 1 <br />EW <br />U 2 <br />23a. DATE OF DEATH (Mo., Day, Yr.) <br />October 15, 2015 <br />To be completed by <br />CORONER'S PHYSICIAN <br />or COUNTY ATTORNEY <br />ONLY <br />24a. DATE SIGNED (Mo., Day, Yr.) <br />24b. TIME OF DEATH <br />23b. DATE SIGNED (Mo., Day, Yr.) <br />October 16, 2015 <br />23c. TIME OF DEATH <br />05:40 PM <br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) <br />24d. TIME PRONOUNCED DEAD <br />3 <br />15 0 23d. To the best of my knowledge, death occurred at the time, date and place <br />and due to the cause(s) stated. (Signature and Title( <br />l Kimberly A. Mickels, MD <br />24e. On the basis of examination and/or investigation, in my opinion death occurred at <br />Me time, date and place and due to the cau e(s) stated. (Signature and Title) <br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑YES ® NO <br />26b. WAS CONSENT GRANTED? <br />Not Applicable if 26a is NO 0 YES ❑ NO <br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print <br />Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 <br />r <br />128a REGISTRAR'S SIGNATURE 0 6 - -v <br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) <br />October 16, 2015 <br />I <br />DATE OF ISSUANCE <br />201602392 <br />10/20/2015 <br />STATE OF NEBRASKA <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 HEALTH AND <br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITALLREC19141 ?S, <br />IIUMAN� FF./CAS S ` <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVJCES <br />CERTIFICATE OF DEATH <br />STANLEX- bbPP: <br />A STATE REGISZR,4 <br />DEPART ENT OF HEALTH. ANDA, <br />LINCOLN, NEBRASKA <br />15 06009 <br />