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STATE OF NEBRASKA 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 OF ISSUANCE 04/18/2016 LINCOLN NEBRASKA 201602758 STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Jeanine Louise Fisher 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Junction, 7. SOCIAL SECURITY NUMBER 524 -98 -4751 8b. FACILITY -NAME (11 not Institution, give street and number) 2518 Pioneer Blvd 0 8c. CITY OR TOWN OF DEATH (Include Zip Code) lY o Grand Island 68801 8a. RESIDENCE -STATE ILI Nebraska 15. METHOD OF:UISPOSITION ❑Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal ❑ Othar.(Specify) 22a, DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT'WORK? ❑ YES ❑ NO 23a. DATE OF DEATH (Mo., Day, Yr.) •April 11, 2016 23b. DATE SIGNED (Mo., Day, Yr.) April 11, 2016 1 --- 9b. COUNTY Hall iea. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Urtk.) No IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting in death DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) Metastatic Lung Cancer any, leading to the cause listed on line a 20. IP'EEMALE: • ® Not ptegnantwithin pastyear ❑ Pregnant at time of death 0 N trt pregnant. hut pregnant within 42 days of death ❑ Net pteghattt, but pregnant 41 days to 1 year before death • ❑ t7nknown ifpregnantwdhih the past year t1 I LL F ' < 2 W J E u z Q 3d. To the best of my knowledge, death occurred at the time, date and place 2 C and due to the cause(s) stated. (Signature and Title) Katie L. Peters, APRN 5a. AGE - Last Birthday (Yrs.) 5 16a. EMBALMER - SIGNATURE Not Embalmed 54. UNDER 1 YEAR MOS. 9c. CITY OR TOWN Grand', Island DAYS LL "1 9d. STREET AND NUMBER 2518 Pioneer Blvd 19e, APT. NO. 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 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68801 10b.: NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Charles Fredrick Fisher 11. FATHER'S -NAME (First, Middle, Last, Suffix) Gilbert W Strakey 1 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Patricia L Stroh 14a. INFORMANT -NAME Fred Fisher 16b. LICENSE NO. 3. DATE OF DEATH (Mo., Day, Yr.) April 11, 2016 February 5, 6. DATE OF BIRTH (Mo., Day; Yr.) 9g. INSIDE CITY LIMITS' ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT. Spouse 16c. DATE (Mo., Day Yr.) April 12, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska CAUSE OF DEATH (See instructions and examples) DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c ) (disease or injury that initiated onset to death 1 Year onset to death Hours APPROXIMATE : I N TER VAL 18 PART I. Enter the of 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 line. Add additional lines if necessary. the events tasulti LAST s. n death) ;.; DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. DM 11, History : 0f Bladder Cancer 22b. TIME OF INJURY 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could l not be determined 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODs= 23c. TIME OF DEATH 01:35 PM 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ Pedestrian 0 Others (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) I 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? tGl YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE I • ATION BEEN CONSIDERED? ❑ YES g NO 28a. REGISTRAR'S SIGNA'TURE� 1 17b. Zip Code 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES D NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 24b. TIME OF DEATH 24d. TIME PRONOUNCED D D 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Katie L. Peters, APRN, 729 North Custer Avenue, PO Box 2339, Grand nd, Nebraska, 68803 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) April 15, 2016