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MAO Pktit STATE OF NEBRASKA TIVZ ,xm 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 201606964 9/13/2016 LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Darlene Joyce Whitefoot 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, respiratory arrest or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines R necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Chronic Obstructive Lung Disease disease or condition resulting APPROXIMATE INTERVAL. onset to death Years 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Boelus, Nebraska 7. SOCIAL SECURITY NUMBER 505-30-1577 8b. FACILITY -NAME (It not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE LI Nebraska LL 9d. STREET AND NUMBER 7, 2115 N. Huston Avenue t ltla MARITAL STATUS AT TIME OF DEATH 151] Married 0 Never Married 9t ❑Married, but. separated Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Link) NO 15. METHOD OF DISPOSITION 1 2 Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 5a. AGE - Last Birthday (Yrs.) 85 9b. COUNTY Hall 16a. EMBALMER-SIGNATURE Chris McCoy 5b. UNDER 1 YEAR M OS. 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA DAYS 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 3. DATE OF DEATH (Mo., Day, Yr.) August 30, 2016 6. DATE OF BIRTH (MO., Day, Yr.) February 8, 1931 ❑ Hospice Facility 9c, CITY OR TOWN Grand Island' 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS 2 YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Richard Wayne Whitefoot 1. FATHER'S - NAME (First, Middle, Last, Suffix) August H Bremer ta 12. MOTHER'S-NAME (First, Middle, Maiden Surname) Agnes Hansen 14a. INFORMANT -NAME Patricia McFeely 16b. LICENSE NO. 1191 7a. FUNERAL HOME NAM E 'AND MA LING ADDRESS (Street, City or Town, State) ADfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska 14b. RELATIONSHIP TO DECEDENT Niece 16c. DATE (Mo., Day, Yr.) September 7, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Westlawn Cemetery Grand Island STATE Nebraska 17b. Zips 68801 CAUSE OF DEATH (See instructions and examples) in death) DUE TO, OR AS A CONSEQUENCE OF: • equentianylint "b) Respiratory Failure any, leading to the Cause listetl on line a onset todeath Days DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury that initietee onset to death the events result LAST n death) DUE TO, OR AS A CONSEQUENCE OF: d) onset tedeath 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. OAF ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant. but pregnant within 42 days of death ❑ Not pregnant, but pfegnam 43 days to 1 year before death ❑ Unknown if pregnant w thinthe past year E 22a. DATE OF INJURY (Mo., Day, Yr.) v 22d. INJURY AT 1?MORK? •W ❑YES ❑ NO • 22b. TIME OF INJURY 22f. LOCATION OF INJURY •STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE 23e. DATE OF DEATH (Mo., Day, Yr.) Aucivat 30 2016 23b. DATE SIGNED (MO., Day, Yr.) September 7, 2016 23c. TIME OF DEATH 04:36 PM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Michael A. Donner, MD 5. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES 0 NO ❑ PROBABLY ❑ UNKNOWN 22e. DESCRIBE HOW INJURY OCCURRED 28a, REGISTRAR'S SIGNATURE 6 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 2 NO 21b. IF TRANSPORTATION INJURY Driver /Operator ❑ Passenger 0 Pedestrian 0 Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 74c. PRONOUNCED DEAD (Mo., Day, Yr.) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 21c. WAS AN AUTOPSY PERFORMED? ❑YES 511 NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? ;. ❑ YES ❑ NO 24b. TIME OF DEATH 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 Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Michael A. Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28b. DATE FILED BY REGISTRAR (Me, Day, Yf:) September 7, 2016