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To be completed by: CERTIFIER 1 1 To be completed /verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Esther Marie Brandon 2. SEX Female '3. DATE,OFDEACTH (Mo., Day, Yr.) October 13, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Eufaula, Oklahoma 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) October 15, 1929 (Yrs.) 85 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -90 -3229 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 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 Doniphan 9d. STREET AND NUMBER 109 East Plum Street 9e. APT. NO. 9f. ZIP CODE 68832 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 Jimmie Franklin Brandon 11. FATHER'S -NAME (First, Middle, Last, Suffix) Robert Buie 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Bertha Brown 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Deborah Markworth 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Derek Apfel 16b. LICENSE NO. 1240 16c. DATE (Mo., Day, Yr.) October 16, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Cedarview Cemetery Doniphan Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 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 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) Aspiration Pneumonia Days disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, it b} Dysphagla i Days any, leading to the cause listed I on Tine a. DUE TO, OR AS A CONSEQUENCE OF: I onset to death Enter the UNDERLYING CAUSE c) Encephalopathy 1 Days (disease or injury that Initiated . the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death LAST d)Acute Renal Failure : Days I 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given In PART I. Cerebrovascular Disease 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 IE Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ suicide ❑ could not be 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? OYES ONO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE a W 1 F E u z 23a. DATE OF DEATH (Mo., Day, Yr.) October 13, 2015 z S g. I d ° ° 3 s' c W 2 B p V ~ u o 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 23b. DATE SIGNED (Mo., Day, Yr.) October 14, 2015 23c. TIME OF DEATH 11:17 PM u a 0 23d. To the best of my knowledge, death occurred at the time, date and place a C and due to the cause(s) stated. (Si and Title) '- 2 Michael A. Donner, MD 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? 26a. HAS ORGAN OR ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME. TITLE AND ADDRESS OF CERTIFIER (Type or Print / .' I d Nobs nnLn 68!r1 M ichael A. Donner, MD, 72 Norm Custer Avciit:v, vr�r:,, Is,: ^,., . �. _ 128a. REGISTRAR'S SIGNATURE ' __ v � !/� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 16, 2015 STATE OF NEBRASKA 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 bEPAfTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECQI DSt DATE OF ISSUANCE 10/20/2015 LINCOLN, NEBRASKA STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S COOPER ASSI TA T STATE RE'015TI AR DEPARTAgEN1 HEALTH'AID HUMAN SE`I V, ES' 201606072 15 06000