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iT ` � � IF,.x v' i i "P,a 1i. ,I t n. i�i" J . ai£'fft 7U '4�i#I ='r 4 I (u a � � ,i }i, :iw g ` STATE OF NEBRASKA �,�) t `d � � k 4 7N� . 9 r- • ia ,P Y Xz , / 1 , , � , WHEN ! THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT "N.,. CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD 04 TE hyON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL � `'•" !%,\ RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS 64441 -�` %) DATE OF ISSUANCE s STANLEY S.COOPER 1I d *-..„ `744- k/g 7/13/2016 a ASSISTANT STATE REGISTRAR lit '" m DEPARTMENT HEALTH AND 'it ,4U > HUMAN SERVICES \\i�\RCx i Aa LINCOLN,NEBRASKA STATE OF NEBRASKA-DEPARTMENT OF HEALTH!AND HUMAN SERVICES CERTIFICATE OF DEATH � � 1.DECEDENT'S-NAME (First, Middle, Last, Suffix) 2.SEX 3.DATE OF DEATH(Mo.,Day,Yr.) Betty Joyce Ray Female April 9,2014 4.CITY AND STATE OR TERRITORY,OR FOREIGN COUNTRY OF BIRTH 5a.AGE-Last Birthday 5b.UNDER 1 YEAR 5c.UNDER 1 DAY 6.DATE OF BIRTH(Mo,Day,Yr.) (Yrs.) MOS. DAYS HOURS MINS. Oconto,Nebraska 71 January 13, 1943 7.SOCIAL SECURITY NUMBER 8a.PLACE OF DEATH 508-44-9837 HOSPITAL ❑Inpatient OTHER ❑Nursing Home/LTC ❑Hospice Facility 8b.FACILITY-NAME(If not Institution,give street and number) K ❑ER/Outpatient ®Decedent's Home V 7 Venus St. ❑DOA ❑Other(Specify) x 8c.CITY OR TOWN OF DEATH(Include Zip Code) 8d.COUNTY OF DEATH a Alda 68810 Hall l 9a.RESIDENCE-STATE - 9b.COUNTY 9c.CITY OR TOWN Nebraska Hall Alda _ 9d.STREET AND NUMBER 9e.APT.NO. 9f.ZIP CODE 9g.INSIDE CITY LIMITS >, 7 Venus St. 68810 III YES ❑ NO a 'c 10a.MARITAL STATUS AT TIME OF DEATH®Married ❑Never Married 10b.NAME OF SPOUSE(First, Middle, Last, Suffix)If wife,give maiden name m ❑Manied,but separated ❑Widowed ❑Divorced ❑Unknown Gerald Ray > ` .a 11.FATHER'S-NAME (First; Middle, Last, Suffix) 112.MOTHER'S-NAME (First, Middle, Maiden Surname) w Elmer Flint I Ruth •Wright E 13.EVER IN U.S.ARMED FORCES?Give dates of service if Yes. 14a.INFORMANT-NAME 14b.RELATIONSHIP TO DECEDENT E u (Yes,No,or urntc.)No Jodi Kister Daughter .15.METHOD OF DISPOSITION 16a.EMBALMER-SIGNATURE 16b.LICENSE NO. 16c.DATE(Mo.,Day,Yr.) 19,. ❑Burial ❑Donation Not Embalmed April 11,2014 ®Cremation 0 Entombment 16d.CEMETERY,CREMATORY OR OTHER LOCATION CITY/TOWN STATE ❑Removal 0 Other(Specify) Central Nebraska Cremation Services Gibbon Nebraska 17a.FUNERAL HOME NAME AND MAILING ADDRESS(Street,City or Town,State) 17b,Zip Code All Faiths Funeral Home.2929 S.Locust Street.Grand Island.Nebraska 68801 CAUSE OF DEATH(See instructions and examples) le.PART L 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)Respiratory Arrest Immediate disease or condition resulting In death) DUE TO,OR AS A CONSEQUENCE OF: onset to death. Setiuentially Sat conditions,if b)Non Small Cell Lung Cancer 5 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 evemsrasulting 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. 19.WAS MEDICAL EXAMINER OR CORONER CONTACTED? W ❑YES ®NO u„_ 0.IF FEMALE: 21a,MANNER OF DEATH 2113.IF TRANSPORTATION INJURY 21c.WAS AN AUTOPSY PERFORMED? M ®:Not pregnant within past year ®Natural ❑Homicide ❑Driver/Operator CC ❑ YES ® NO ' U ❑Pregnant at time of death ❑Accident ❑Pending Investigation ❑Passenger -- Not pregnant,but pregnant within 42 days of death ❑Pedestrian 21d.WERE AUTOPSY FINDINGS AVAILABLE d ❑ Suicide Could not be determined 0 Not pregnant,but pregnant 43 days to 1 year before death ❑ ❑ ID TO COMPLETE CAUSE OF DEATH? Other(Specify) ❑Unknown if pregnant within the past year ❑ YES ❑ NO S 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) 0 t) 42;22d.INJURY ATWORK? 22e.DESCRIBE HOW INJURY OCCURRED .-0 ❑Y 22f.LOCATION OF INJURY-STREET&NUMBER,APT.NO. CITY/TOWN STATE ZIP CODE ' 23a.DATE OF DEATH(Mo.,Day,Yr.) 124a.DATE SIGNED(Mo.,Day,Yr.) 24b.TIME OF DEATH A'5 April 9 2014 .u 2 1 8 F 23b.DATE SIGNED(Mo.,Day,Yr.) 23c.TIME OF DEATH y v 24c.PRONOUNCED DEAD(Mo.,Day,Yr.)24d.TIME PRONOUNCED DEAD 1 0 z April 9,'2014 09:30 AM E "J Y < 0 3d.To the best of my knowledge,death occurred at the time,date and place 8 m i O 34e.On the basis of examination and/or investigation,in my opinion death occurred at 8 c and due to the cause(s)stated.(Signature and Title) .5 2 the time,date and place and due to the causes)stated.(Signature and Title) g, Michael A.:Aonner,MD 8;° 25 DID TOBACCO Lite CONTRIBUTE TO THE DEATH? 26a.HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b.WAS CONSENT GRANTED? YES []NO '❑PROBABLY 0 UNKNOWN ❑YES igi NO Not Applicable if 26a is NO ❑YES ❑NO 27.NAME,TITLE AND ADDRESS OF CERTIFIER(Type or Print) (] Michael A.Donner,MD,729 North Custer Avenue,Grand Island,Nebraska,68803 28a,REGISTRARS SIGNATURE I�.�_ / 2811 DATE FILED BY REGISTRAR(MD.,Day,Yr,) f P April 10,2014 01 GI CJl CY)