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To be completed /verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Lyman Edward Sigler 2. SEX , ' j , , ,, Male 3.'0ATE OF DEATH (Mo., Day, Yr.) ' , April 26, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sherman County, Nebraska 5a. AGE - Last Birthday (Yrs.) 85 5b. UNDER 1 YEAR 5c. UNDER 1 DAY' 6. DATE OF BIRTH (Mo., Day, Yr.) May 19, 1929 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -30 -8413 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 8a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 520 N. Custer Ave 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Margaret Mary Lepant 11. FATHER'S -NAME (First, Middle, Last, Suffix) William Allen Sigler 12. MOTHER'S -NAME (First, Middle, Malden Surname) Beulah Conrad 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Margaret Mary Sigler 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION IXI Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Katie M. Smydra 16b. LICENSE NO. 1454 16c. DATE (Mo., Day, Yr.) April 30, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island 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 17b. Zip Code 68801 To be completed by: CERTIFIER CAUSE OF DEATH (See instructions and examples) 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 1 Day 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) Respiratory Failure disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death Sequentially list conditions, if b)Aspiration Pneumonia 1 3 Weeks any, leading to the cause listed I I on line a. DUE TO, OR AS A CONSEQUENCE OF: I onset to death Enter the UNDERLYING CAUSE c) Stroke 15 Years (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) I 1 18. PART Il. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART L Congestive Heart Failure, Chronic Obstructive Pulmonary Disease. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of deat h ❑ 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 ❑ DriverfOperator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El 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? OYES ❑ NO. 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE SW i F ° 6 z 21n. DATE OF DEATH (Mo.. Day, Yr.) April26,2015 'oi j y c 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) A pril 28, 2015 23c. TIME OF DEATH 05:18 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD ti O 23d. To the best of my knowledge, death occurred at the time, date and place g I] and due to the cause(s) stated. (Signature and Title) Isaac J. Berg, MD u w z 24e. On the basis of examination and /or investigation, in my opinion death occurred at g L u the time, date and place and due to the cause(a) stated. (Signature and Title) I- ii a 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 1 ❑ YES i7 • 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Gra • Island, Nebraska, 68803 1 28a. REGISTRAR'S SIGNATURE - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) April 28, 2015 DATE OF ISSUANCE 05/01/2015 STATE OF NEBRASKA 201605929 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL 4,K HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA 1 DEPAA ' TMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FQR V, L--ttLLCOR(3S STANLEY ` COOPER -ASSISTANT- STAT . REGIgRR 2 VEPAR7ma6T f EAL7H'AMD , HUMAN SERVICES. LINCOLN, NEBRASKA L STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SkRVICES CERTIFICATE OF DEATH. 15 02461