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To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Lorraine Ann Hultquist 2. SEX - Female - 3.ODATE OF DEATH (Mo., Day, Yr.) ' August 26,-2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH West Point, Nebraska 5a. AGE - Last Birthday (Yrs.) 73 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) October 4, 1938 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -50 -5633 8b. FACILITY -NAME (If not Institution, give street and number) Wedgewood Care Center 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 1520 N. Taylor Se. 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 lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Gordon Hultquist 11. FATHER'S -NAME (First, Middle, Last, Suffix) Rolland VonSeggern 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Valna Woerman 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Gordon Hultquist 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) August 31, 2012 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) I I 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 6 Months 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) Failure To Thrive disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Cardiomyopathy 6 Months 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: 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. Lymphoma, hypertension, malnutrition 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® 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 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 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE B W i Y E 0 i 23a. DATE OF DEATH (Mo., Day, Yr.) August 26, 2012 I To be completed by I CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) August 27, 2012 23c. TIME OF DEATH 09:30 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD $ a 0 3d To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) l Ryan D. Crouch, DO 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 ❑ 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 128a. REGISTRAR'S SIGNATURE,/ ii+ ]/y {IOQ�V 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I August 29, 2012 • STATE OF NEBRASKA 201604322 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA J9 RTMENT OF HEALTH AND HUMAN S E R V I C E S , V I T A L RECORDS O F F I C E , W H I C H I S T H E LEGAL DEPOSITORY FOR VL tL !<FQRQS DATE OF ISSUANCE 09/04/2012 CERTIFICATE OF DEATH S `AJkIIEY O .Q PE R � ` EGIS R ,A- S , S. STATE C R TRA ;� ` t EF T 6 A H AND) /`' MA LINCOLN, NEBRASKA HU NS V+C'E -.� o STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERV -12 03143