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STATE OF NEBRASKA 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 OF ISSUANCE 7/14/2016 LINCOLN, NEBRASKA 201605153 Cori STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH re Ct cc K J Q OK a 7 L m 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married • E El Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S-NAME (First, Middle, Last, Suffix) v m Earl Schulz a E lu N . K W U 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Devon LeAnn Hamner 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Akron, Iowa 7. SOCIAL SECURITY NUMBER 503 -54 -4468 80. FACILITY -NAME (If not Institution, give street and number) 603 Sweetwood Drive 90. RESIDENCE- -STAT Nebraska DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c ) (disease or injury , that initiated The events resulting in dee" DUE TO, OR AS A CONSEQUENCE OF: LAST d) 23a. DATE OF DEATH (Mo., Day, Yr.) July 4, 2016 .5 3b. DATE SINNED (Mo., Day, Yr.) 23c. TIME OF DEATH ''"" July 6, 2016 12:40 PM u a O 3d. To the best of my knowledge, death occurred at the time, date and place 2 o and due to the cause(s) stated. (Signature and Title) o z. Ryan Rarnaekers, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ Y£S ® NO ❑ PROBABLY El UNKNOWN 26a. HAS 0 ❑ YES 5a. AGE - Last Birthday (Yrs.) 50. UNDER 1 YEAR MOS. 65 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient P ER/outpatient ❑ 00A 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9b. COUNTY Hall 9d. STREET AND NUMBER 603 Sweetwood Drive DAYS 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) July 4, 2016 6. DATE OF BIRTH (Mo., Day, Yr,) April 21, 1951'. OTHER ❑ Nursing Home /LTC Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 9e. APT. NO. 9f. ZIP CODE 68803 1011 NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Charles Lee Hamner 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Sanna Haase 9g. INSIDE CITY LIMITS; • ® YES ❑ NO 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME (Yes, No, or Link.) No Charles Lee Hamner 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION ❑`Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Not Embalmed 160.` LICENSE NO. 16c. DATE (Mo., Day, Yr.) July 7, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY I TOWN Gibbon STATE Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska 171, Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 16. PART t. Enter the chain of -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, reepiratiiry arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line; Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Ovarian Cancer Metastatic disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) any, leading to the cause listed on line a AP PROXIM ATE TE RVAL onset to death 1 Year onset to death 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? ❑ YES ®NO 20. I F FEMALE: ®' Not pregnan;within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ t4ot pregnant, but pregnant:43 days to 1 year before death ❑ Unknown if ptagnant withinthe past year 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES 0 N 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 122c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? , 122e. DESCRIBE HOW INJURY OCCURRED ❑ YES ❑NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 24c: PRONOUNCED 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 Tide) AN OR TISSUE DONATION BEEN CONSIDERED? El NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) , July 8, 2016 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ryan Ramaekers, MD, 2116 W. Faidley Avenue, Grand Island, Nebraska, 68803 2 8a. REGISTRARS SIGNATURE ii _ „,,,, 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO