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>J,rR4F 4r x.. STATE OF NEBRASKA ..rte ;;a r ?gASn, as K rZssillvita 4 4 s dh✓ Oak W it 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 OP ISSUANCE 03/21/2016 LINCOLN, NEBRASKA 2016038 STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH O U W a 0 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Sharon Kay Garrison 4, CITYIANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH St. Paul, Nebraska 7. SOCIAL SECURITY NUMBER 508 -52 -0004 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE-STATE Nebraska 9d. STREET AND NUMBER 439 E. Dodge St. 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated ;; ❑ Widowed ® Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Albin Michalek l3. EVER IN U.S ARMED FORCES? Give dates of service if Yes. (Yes, No, or Urik.) NO 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other(Specify) disease or condition resulting in death) _. Sequentially list conditions, if ,. any, leading to the cause listed' on line a. Enter the UNDERLYING CAUSE (disease et injury ; that injGaterl .. the events resulting Ln death) LAST!' 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT:W0RK? ::: (] YES } NQ 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Katie M. Smydra 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Cemetery 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska DUE TO, OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 20. IF FEMALE: J ® 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 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY /TOWN 5a. AGE • Last Birthday {Yrs.) 71 5b. UNDER .1 YEAR MOS. 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island' 14a. INFORMANT- NAME Kraig Garrison 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide 0 Could not be determined •r E u Z 0 12 3d. To the best of my knowledge, death occurred at the time, date and place and due to the causes) stated. (Signature and Title) o !; i 1(ertRettl vettel, MD 73a. DATE OF DEATH (Mo., Day, Yr.) Match 11, 2016 23b. DATE SIGNED (Mo., Day, Yr.) March 14, 2016 23c. TIME OF DEATH 04:40 PM 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Kenneth Vettel, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 DAYS 2. SEX Female 5c. UNDER 1 DAY HOURS 9e. APT. NO. MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mamie Jorgensen 16b, LICENSE NO. 1454 CITY / TOWN Grand Island CAUSE OF DEATH (See instructions and examples) 18. PART 1. Enter the chain of events -- diseases, injuries, or complicationsdhat directly caused the death. DO NOT entertemtinai events such as cardiac arrest, respiratory arrest dt ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause On a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a). End Stage Chronic Obstructive Pulmonary Disease With Respiratory Failure 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21b. 1F TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger 0 Pedestrian ❑ other (Speedy) 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) STATE 24a. DATE SIGNED (Mo., Day, Yr.) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? YES [] NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR Tissue DONATION BE ❑ YES 12 NO EN CONSIDERED? 28a. REGISTRAR'S SIGNATURE /1r AO- a May 23, 1944 9f. ZIP CODE 68801 3. DATE OF DEATH (Mo., Day, Yr.) March 11, 2016 6. DATE OF BIRTH (Mo., Day, Yr,) 14b. RELATIONSHIP TO DECEDENT. Son 16c. DATE (Mo., Day, Yr.) March 16, 2016 17b, Zip Code 68801 APPROZIMATE INTERVA; Onset to death 2 Days onset to death onset to death onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES Ix.) No 21c. WAS AN AUTOPSY PERFORMED ? ❑ YES IA NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE.OF DEATH? ❑ YES ID NO 24b. TIME OF DEATH ❑ Hospice Facility 9g. INSIDE CITY LIMITS ® YES ❑ NO STATE Nebraska ZIP CODE 24c.IPRQNOUNCED DEAD (Mo„ Day, Yr.) 24d. TIME PRONOUNCED DEAD 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) 28b. DATE FILED BY REGISTRAR (MODay, Yc) March 16, 2016 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO