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9 y P 4 A , R • . • � , , xZ lakfii&Vri rd r STATE OF NEBRASKA s,. ` .,.. ` WHEN THIS r 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 201605929 DATE OF ISSUANCE 6/6/2016 LINCOLN NEBRASKA STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 0 is W tY 0 J cc 1• LL 9d. STREET AND NUMBER >, 520 North Custer Ave. E w 1. DECEDENTS - NAME (First, Middle, Last, Suffix) Margaret Mary Sigler 4. CITY STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Anselmo, Nebraska' 7. SOCIAL SECURITY NUMBER 506 -30 -7744 8b. FACILITY -NAME (if not Institution, give street and number) 520 North Ouster Ave. 9a. RESIDENCE -STATE Nebraska 11 EVER IN U.S. > ARMED : Give dates of service if Yes. (Yes, No, or Unk.) No 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) Enter the UNDERLYING CAUSE (disease or injurythat initiated. .... in death the event LAST:' 20.IFFEMALE: ❑ Not pregnant Within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days tot year before death Unknown if Pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY ATWORK? ❑ YES ❑ NO DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 5a. AGE'. Last Birthday (Yrs.) 9b. COUNTY Hall 21a. MANNER OF DEATH RI Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 5 23a. DATE OE:DEATH (Mo., Day, Yr.) 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH is v u 4 0 3d. To the best of my knowledge, death occurred at the time, date and place g o and due to the cause(s) stated. (Signature and Title) 54. UNDER 1 YEAR MOS DAYS 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ® Decedent's Home ❑ Other(Specify) ❑ Hospice Facility 9c. CITY OR TOWN Grand Island" Lyman Edward Sigler 9e. APT. NO. 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 9f. ZIP CODE 68803 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married 0 Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name ❑ Mantled, Out separates = xi Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Joseph Frank Lepant I 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Dorothy Cecelia Rich 14a. INFORMANT -NAME Terry Sigler 16a. EMBALMER - SIGNATURE Katie M. Smvdra 18. PART 1I. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Acute Pancreatitis 26a. HAS ORGAN OR TISSUE a • ❑ YES 7 • 3. DATE OF DEATH (Mo., Day, Yr.) May 25, 2016 6. DATE OF BIRTH (Mo., Day, Yr.) February 13, 1930 8d. COUNTY OF DEATH Hall 164, LICENSE NO. 1454 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ Pedestrian Other (Specify) STATE 9g. INSIDE CI IY LIMITS 3 ® YES O NO 14b. RELATIONSHIP TO DECEDENT Son 16c. DATE (Mo., Day, Yr.) May 31, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Grand Island City Cemetery Grand Island STATE Nebraska CAUSE OF DEATH (See instructions and examples) 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, Monetary arrest, Or itular fibrillation without showing Ole etiology. DO NOT ABBREVIATE. Enter only one cause an a Tine. Add additional lines If necessary. IMMEDIATE CAUSE: a) Unknown Natural Causes IMMEDIATE CAUSE (Final disease or condition resulting APPROXIMATE :;INTERVAL onset to death Minutes In death). Sequentially rest doltditiens, if any,teading to the cause Listed on line s. DUE TO, OR AS A CONSEQUENCE OF: D) Congenital Heart Disease onset to death Months DUE TO, OR AS A CONSEQUENCE OF: c) onset to death onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO Y P 21c. WAS AN AUTOPSEiRFORMED7 ❑ YES ® NG 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22r. PLACE' OF INJURY -At hone, farm, street, factory, office building, construction site, etc.:(Specify) 24b. TIME OF DEATH Approx. 05:00 AM 24d. TIME PRONOUNCED DEAD 07:05 AM 24a. DATE SIGNED (Mo., Day, Yr.) May 26, 2016 24c. PRONOUNCED DEAD (Mo., Day, Yr. May 25, 2016 24e. On the basis of examination and /or investiga Ion, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title). Megan Alexander, Hall Deputy County Attorney A TI ON BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO © YES ❑ NO 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? YES ❑ NO ❑ PROBABLY ® UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Megan Alexander, Hall Deputy County Attorney, 231 S. Locust, P • Box 367, Grand Island, Nebraska, 68802 28a, REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo,, Day, Yr �" June 1, 2016 Color