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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTti64.41CIDY/UMAIII SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH { THE NEBR4 Kq,ICIEPINR1*? NT b HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR'V KAL::Rk0;) S DATE OF ISSUANCE 09/11/2014 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE$ ' 1 CERTIFICATE OF DEATH 9 1'01603 6 ST4)VLEY,SCOOPER AccIS74NT_STATE REGIS 68134IiTMENf'OE HEALTH A LINCOLN, NEBRASKA HUMAN SERVICES 4:04538 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Helen Elizabeth Riese 2. SEX Female a. DATP OR 04,1rt,tox Day, Yr.) A ' ep`tember 9; 2 014 ' 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Rural Stapleton, Nebraska 5a. AGE - Last Birthday (Yrs•) 97 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF 8(1kTN,(Mo., Day, Yr.) August 14, 1917 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -18 -7960 8b. FACILITY -NAME (If not Institution, give street and number) 606 S. Broadwell Av 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 606 S. Broadwell Av 9e. APT. NO. 9f. ZIP CODE I 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated ® Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Walter Riese 11. FATHER'S -NAME (First, Middle, Last, Suffix) George W Kramer 12. MOTHER'S -NAME (First, Middle, Maiden Sumame) Ella Sherman 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or link.) No 14a. INFORMANT -NAME Jennifer Morgan 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) September 10, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 14. 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, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final a) Failure To Thrive 6 Months disease or condition resulting 10 death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, it b)Advanced Age any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) 1 t 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Comfort Care 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 110 NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ could not be determined 21b. IF TRANSPORTATION INJURY ❑ DriverlOperator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE B 5 t F E z 23a. DATE OF DEATH (Mo., Day, Yr.) September 9, 2014 s g z g I E3° - < -- ° C 0 2 2 A ~ g o 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) Se ptember 9, 2014 23c. TIME OF DEATH I 08:30 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD G 3d. To the best of my knowledge, death occurred at the time, date and place E g and due to the cause(s) stated. (Signature and Title) o 2 I- s Ryan D. Crouch, DO 24.- on the i nt s. s:neaon endrw investigation, m my opinion death occurred at the time, data and place and due to the causeis) (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803 t 8a . REGISTRAR'S SIGNATURE _ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) September 10, 2014 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTti64.41CIDY/UMAIII SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH { THE NEBR4 Kq,ICIEPINR1*? NT b HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR'V KAL::Rk0;) S DATE OF ISSUANCE 09/11/2014 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE$ ' 1 CERTIFICATE OF DEATH 9 1'01603 6 ST4)VLEY,SCOOPER AccIS74NT_STATE REGIS 68134IiTMENf'OE HEALTH A LINCOLN, NEBRASKA HUMAN SERVICES 4:04538