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To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Luella Grace Grams 2. SEX ' , ' Female 3. DATE OF - DEATH (Mo., Day, Yr.) June 13, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Hallam, Nebraska 5a. AGE - Last Birthday (Yrs.) 90 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) January 3, 1923 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -26 -3856 8b. FACILITY -NAME (If not Institution, give street and number) Good Sam. Society- Hastings Village, Perkins Pay. Ba. 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) Hastings 68902 8d. COUNTY OF DEATH Adams 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Doniphan 9d. STREET AND NUMBER 308 N 1st Street 9e. APT. NO. 9f. ZIP CODE 68832 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 Dale L Grams 11. FATHER'S -NAME (First, Middle, Last, Suffix) Edward Messman 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ella Geistlinger 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Dale L Grams 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE James M. McLaughlin 16b. LICENSE NO. 951 16c. DATE (Mo., Day, Yr.) June 21, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Fort McPherson National Cemetery Maxwell Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livingston - Butler - Volland Funeral Home, 1225 N. Elm, Hastings, Nebraska 17b. Zip Code 68901 r CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER I 18. 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 onset to death 10 Mins 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: IMMEDIATE CAUSE (Final a) Cardiopulmonary Arrest disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) Congestive Heart Failure any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Arteriosclerotic Cardiovascular Disease (disease or injury that Initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART I. Dementia, Alzheimers Type 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 0 N 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 ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ' ❑ YES ®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 ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE b' W 2 $ 2 3b. I d al 23a. DATE OF DEATH (Mo., Day, Yr.) June 13, 2013 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH DATE SIGNED (Mo., Day, Yr.) June 17,2013 23c. TIME OF DEATH I 03:30 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD q 0 3d. To the best of my knowledge, death occurred at the time, date and place 8 .51 and due to the cause(s) stated. (Signature and Title) a Richard French, MD 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) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES © NO ❑ PRODA3LY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES El NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Richard French, MD, 2115 N Kansas Avenue, Hastings, Nebraska, 68901 128a. REGISTRAR'S SIGNATURE JO - l� /� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I June 18, 2013 *. STATE OF NEBRASKA 201604294 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAVZ l4UMA V SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBIA.SKAt P T HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY F,CR DATE OF ISSUANCE 06/21/2013 ANLF v .GO P `.' AIS71lV TETRAR Q PARTMEN HEALTH ,AND LINCOLN, NEBRA REGI, K A A TE OF NEBRASKA - DEPARTMENT OF HEALTH AND H M4A,SERVICCS HUMAN SERYtCEA ;r s r t' , yw, CERTIFICATE OF DEATH