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STATE OF NEBRASKA
<br />WHEN THIS ' COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />: DATE OP ISSUANCE
<br />04/06/2016
<br />LINCOLN, NEBRASKA
<br />201602651
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH! AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Dixie D Scott- Fringer
<br />t PART 1. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. 00 NOT enter terminal events such as cardiac arrest,
<br />iratory arrest, of ventricular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines H necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Stage 7 Alzheimers Dementia
<br />disease or condition resulting
<br />in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)ACOUStic Neuroma
<br />APPROXIMATE INTERVAL
<br />Years
<br />onset to deat?t'
<br />Years
<br />4. CITY: ANA STATE QR T
<br />Clarks, Nebraska
<br />RRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />7. SOCIAL SECURITY NUMBER
<br />508 -52 -1480
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />,t
<br />Hittcrest Nursing Home
<br />W • 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />F5 McCook 69001
<br />g 9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />2304 N Sherman St
<br />9b. COUNTY
<br />Hall
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />75
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married
<br />0 Married, but separated; El Widowed ❑ Divorced ❑ Unknown
<br />� • 11. FATHER'S -NAME ( First, Middle, Last, Suffix)
<br />• Curtis Schwartz
<br />1.9. EVER IN U.S.; ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) No
<br />1
<br />15. METHOD OF DISPOSITION
<br />0
<br />Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Removal 0 Other {Specify)
<br />Seguentialfy ttst nortdmons, d
<br />any, leading to the mute Fisted
<br />on ma. DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />rdiseeve or injury that initiated
<br />16a. EMBALMER - SIGNATURE
<br />James L. Jones
<br />1 T 16b. LICENSE NO.
<br />2275
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Evergreen Cemetery
<br />CITY /TOWN
<br />Superior
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Williams Funeral Home, 814 Idaho Street, PO Box 191, Superior, Nebraska
<br />CAUSE OF DEATHJSee instructions and examples)
<br />onset to death
<br />the events resulting in death);::
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />IT 20. IF FEMALE:
<br />N ot pregnant within past year
<br />v W • ❑ 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 />'E3 I o
<br />❑ Unknown if pregnant within the past year
<br />E °' 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />0
<br />• 22d. I NJURY AT WORK/
<br />kA
<br />.0 YES C3 NO
<br />0
<br />22b. TIME OF INJURY
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be detet:mined
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />CITY/TOWN STATE
<br />ZIP CODE
<br />a. DATE OF DEATH (Mo., Day, Yr.)
<br />Marth7, 2016
<br />23b. DATE SIGNED (Mo., Day, 'If.) 237.. TIME OF DEATH
<br />E v z March 9,2016 07:45 PM
<br />u J Q
<br />3d. To the hest of my knowledge, death occurred at the time, date and place
<br />a Q and due to the cause(s) stated. (Signature and Title)
<br />- a Brett R. Lindau, DO
<br />25. DM TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />D YES ID NO ❑ PROBABLY ❑ UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTI IER (Type or Print
<br />Brett R. Lindau, DO, 1401 East H Street, McCook, Nebraska, 69001
<br />28a.3tEG)STRAFt S SIGNATURE
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />HOURS
<br />8d. COUNTY OF DEATH
<br />Red Willow
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />9e. APT, NO.
<br />14a. INFORMANT -NAME
<br />Ronald Flinger
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Oriver /Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />Other (Specify)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES Ea NO
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MINS.
<br />OTHER ® Nursing Home /LTC
<br />❑ Decedent's Home
<br />❑ Other (;pecify)
<br />9f. ZIP CODE
<br />68803
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />March 7, 2016
<br />6. DATE OF BIRTH (Mo., Day, Yr.);;
<br />April 13, 1941
<br />❑ Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10b. NAME OF, SPOUSE (First Middle, Last, Suffix) If wife, give maiden name
<br />Ronald Fringer
<br />12. MOTHERS-NAME (First, Middle, Maiden Sumame)
<br />Mildred Arney
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., bay, Yr.)
<br />March 14, 2016
<br />17b, Zip Code
<br />68978
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑YES .,,® NO
<br />21c. WAS AN AUTOPSY PERFORMED ?;
<br />❑ YES NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH ?.
<br />13 YES 0 N
<br />22c, PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<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 causes) stated. (Signature and Title)
<br />26b. WAS CONSENT GRANTED'?
<br />Not Applicable if 26a is NO ❑ YES
<br />© NO
<br />28b. DATE FILED BY REGISTRAR (MO.,': Yr.)
<br />March 11, 2016
<br />
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