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STATE OF NEBRASKA ifoir 4 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 5/31/2016 LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Audrey M O'Rourke a. PART I. Cnter the chain of events- -diseases, injuries, or complications -that directly caused the death. 00 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 tine. Add additional lines it necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Coronary Artery Disease disease or condition resulting in death) CUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) any, leading to the cattae listed ' on line a. Enter the UNDERLYING CAUSE (disease er injurythat initiated . the events resulting in death) LAST 20. IFiFEMALE: ❑ Not pregnant within past year W ❑ Pregnant at time of death DUE TO, OR AS A CONSEQUENCE OF: C) DUE TO, OR AS A CONSEQUENCE OF: d) ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pte 43 days to 1 year before death i ❑Unknown ifp egnam withig the past year 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Dementia 21a. MANNER OF DEATH Natural ❑ Hornicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger ❑ Pedestrian 0 Other(Specify) APPROXIMATE: INTERVAL onset to death onset to death: onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ENO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? ❑YES 0 N 4. CITY! AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Broken Bow, Nebraska 7. SOCIAL SECURITY NUMBER 507 -14 -3717 Bb. FACILITY -NAME (If not Institution, give street and number) CC 0 tj Tiffany Square Care Center W 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand. Island 68803 lY 9a. RESIDENCE -STATE Nebraska E 9d. STREET AND>NUMBER >, 1518 Hagqe Ave a a 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated', E Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Charles Wolfe 5a. AGE Last Birthday (Yrs.) 95 23a. DATE OF DEATH (Mo., Day, Yr.) j Mav 21, 2016 23b. DATE SIGNED (Mo., Day, Yr.) May 23, 2016 23c. TIME OF DEATH 05:15 AM E u z ou a 0 r 3d. To the best of my knowledge, death occurred at the time, date and place .8 C and due to the cause(s) stated. (Signature and Title) 2 Donald Wirth, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ,. NO ❑ PROBABLY. ❑ UNKNOWN ❑ YES El NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Donald Wirth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 . � " J 6 I c 1 28a.REGISTRAR'SSIGNATURE 5b. UNDER 1 YEAR MOS. DAYS 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 12. MOTHER'S -NAME (First, Marie Larsen 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 2. SEX Female 5c. UNDER 1 DAY HOURS 24a. DATE SIGNED (Mo., Day, Yr.) MINS. OTHER E Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall Middle, Maiden Surname) 3. DATE OF DEATH (Mo., Day, Yr.) May 21, 2016 6. DATE OF BIRTH (Mo., Day, Yr.) February 23, 1 921 ❑ Hospice Facility 19b. COUNTY 9c. CITY OR TOWN Hall Grand Island e. APT. NO. 9f. ZIP CODE 68801 19g. INSIDE C)TY LImiTS 1 YES ❑ NO 1Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Gregory O'Rourke E 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME (Yes, No, or Unk.) Np Sheila Gleason 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE E Burial ❑ Donation Patricia R. Curran 1 16b. LICENSE NO. 1092 16c. DATE (Mo., Day, Yr.) May 25, 2016 ❑ Cremation ❑ Entombment ❑ Removal ❑ Other(Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Grand Island City Cemetery Grand Island STATE Nebraska 7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Curran Funeral Chanel, 3005 S. Locust St., Grand Island. Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) E 22a. DATE OF INJURY (Mo., Day, Yr.) 0 22b. TIME OF INJURY t 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 2d. INJURY ATWORK? 'OYES ❑ NO 1 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE 24b. TIME OF DEATH ICE DEAD 24c PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRON 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 Tide) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES [] NO 28b. DATE FILED BY REGISTRAR (MO., Day, Yr.), May 25, 2016 Gior STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH CO