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<br />STATE OF NEBRASKA
<br />Zriia
<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 OF ISSUANCE
<br />5/26/2016
<br />LINCOLN, NEBRASKA
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Loup City 68853
<br />9a. RESIDENCE -STATE I9b. COUNTY
<br />Nebraska 1 Hall
<br />9d. STREET AND NUMBER
<br />112 N. Beachwood Drive
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married
<br />❑ Married, batseparatec(: ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Ethan Buford Howard
<br />13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No or Unk) NO
<br />15. METHOOOF DISPOSITION
<br />❑ Burial ❑ Donation
<br />E Cremation ❑ Entombment
<br />❑:Removal ❑ Other(Specify)
<br />14a. INFORMANT -NAME
<br />Stephan Ray Dadv.
<br />16a. EMBALMER - SIGNATURE
<br />Laurie D. Sheffield
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />1 9c. CITY OR TOWN
<br />Grand Island'
<br />1013. NAME OF > SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Stephan Ray Dadv
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Georgia Jean Fisher
<br />8d. COUNTY OF DEATH
<br />Sherman
<br />b. LICENSE NO.
<br />1397
<br />CITY/TOM
<br />Gibbon
<br />9g. INSIDE CITY L €Ml'rS
<br />® YES ❑ NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />SPOUSE
<br />16c. DATE (Mo., Day, Yr.)
<br />May 20, 2016
<br />STATE
<br />2'c. TIME OF DEATH
<br />d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Title)
<br />26b. WAS CONSENT GRANTED
<br />Not Applicable if 26a is NO I0 YES
<br />25. DID TOBACCL) USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 0 NO ❑ PROBABLY ® UNKNOWN ❑ YES El NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Michael Janulewicz, Sherman County Sheriff - Deputy Coroner, 630 0 Street, PO Box 456, Loup City, Nebraska, 68853
<br />28a, REGISTRAR'S SIGNATURE A , I armitgot, 28b. DATE FILED BY REGISTRAR (Mo., Day, Vr.}
<br />May 23, 2016
<br />1. DECEDENTS•NAME (First, Middle, Last, Suffix)
<br />Margaret Ann Dady
<br />.CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Broken Bow, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508 -72 -391.2
<br />8b FACILITV.NAME Of not Institution, give street and number)
<br />75049 Hwy 58
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />1S. PART 1. Ente the chain of events -- diseases, injuries. or complications -that directly caused the death. O0 NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricu0r fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause On line Add additional lines 4 necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Heart Attack
<br />disease or condition resulting
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially fist conditions, if b) Lethal Cardiac Arrthytmias
<br />any, leading 10 the cause listed 3:
<br />on line a DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) Occlusive, Calcific Atherosclerotic Heart Disease
<br />(disease or ellurythet insisted
<br />the events resultttg m death/ DUE TO OR AS A CONSEQUENCE OF
<br />LAST'.: ; d) .
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />20. I.F.FEMALE;
<br />E Not pregnant:within past year
<br />❑ Pregnant at time of death
<br />Not pragnan pregnant wi 42 days of death
<br />❑ Atot nt, Out pr qua rit.43 days to 1 year before death
<br />r4nknown pregna d pfegna wdhfia the past y ear
<br />225. DATE OF INJURY (Mo., Day, Yr.)
<br />22d.::1NJURY ATWO
<br />YES ❑ N4
<br />a. DATE OF:OEATH (Mo., Day, Yr.)
<br />230. DATE SIGNED (Mo., Day, Yr.)
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />22b. TIME OF INJURY
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />5a. AGE • Last
<br />(Yrs.)
<br />64
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide 0 Could not be determined
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />22c. PLACE OF INJURY -At ho
<br />irthday 5bi UNDER 1 YEAR
<br />MOS.
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (specify)
<br />CITY/TOWN
<br />5
<br />DAYS
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />210. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />ate
<br />3. DATE OF DEATH (Mo., Day, Yr,(
<br />May15,2016
<br />6. DATE OF BIRTH (Mo, Day, Yr.)
<br />January 17, 1
<br />OTHER ❑ Nursing Home /LTC ❑ Hospice Facility
<br />0 Decedent's Home
<br />E Other (Specify)AirpOrt
<br />APPROXIMATE > (NTERVAL .
<br />onset to desth
<br />Minutes
<br />onset to deat
<br />Minutes
<br />onset to death
<br />Years
<br />onset Lade
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES NO
<br />21c. WAS AN AUTOPSY PERFORM
<br />E YES ❑ NO
<br />52
<br />70, Zip;Code
<br />68801 •
<br />21d. WERE AUTOPSY FINDINGS AVAILABL
<br />TO COMPLETE CAUSE OF DEATH?
<br />E YES ❑ NO
<br />e, farm, street, factory, office building, construction site, etc. (Specify)
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />May 18, 2016 Approx. 09::31 ,.pm
<br />4c. PROIQUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />Mav15,2016 09:45 PM
<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 />Michael Janulewicz, Sherman County Sheriff- Deputy. Coroner
<br />
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