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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE MAR 1 0 2008 LINCOLN, NEBRASKA STATE OF NEBRASKA 201607317 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SIRS/IC CERTIFICATE OF DEATH RC ? 5 o,D y,rn) Febfuaty 29, 2008 9d. STREET AND NUMBER 649 MacArthur 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Linda Arlene Eilts 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 505 -54 -4431 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center • 9a. RESIDENCE-STATE LL LL • Nebraska v a� G1 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Middle, Last, Suffix) a. E 11. FATHER'S -NAME (First, O • John Ellis to 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. O (Yes, No, or Unk.) No 15. METHOD OF DISPOSITION ❑ burial ❑Donation ® Cremation ❑Entombment 0 Removal ❑Other(Specity) 22a. DATE OF INJURY (Mo., Day, Yr.) 0. E O • (disease or injury that initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: LAST ,y � 2 , 0 , . � IF FEMALE: tlO 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 22d. INJURY AT WORK? ❑ YES [OAK 23a. DATE OF DEATH (Mo., Day, Yr.) February 29, 2008 23b. DATE SIGNED (Mo., Day, Yr.) March 3, 2008 25. DID TOBACCO U BONTRIBUTE TO THE DEATH? ❑ YES 10 ❑ PROBABLY ❑ UNKNOWN 28a. REGISTRAR'S SIGNATURE 9b. COUNTY Hall 22b. TIME OF INJURY 23e. TIME OF DEATH 09 :55 Am dge, death occurred at the time, date and place (Signature Title) 5a. AGE -Last Birthday 5b. UNDER 1 YEAR (Yrs.) MOS. 62 J 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 14a. INFORMANT -NAME James Eilts 16a. EMBAL IGNATURE _ a.1‘A) k 18. PART IL OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART I. W /► I t 21a. OF DEATH atural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined a OZ lY Z. O a.< J oago 1 - • V o DAYS HOURS 9e. APT. NO. 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES NO 5c. UNDER 1 1:)44 MINS. I Marc 91. ZIP CODE 68801 16b. LICENSE NO. /`'7 MAR 6 2008 OF meta pa.. Day, Yr.) ,1945 8a. PLACE OF DEATH HOSPITAL; © Inpatient OTHER: ❑ Nursing Home/LTC ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other(Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) I wife, give maiden name. James Eilts 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ruby Schutt 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 14b. RELATIONSHIP TO DECEDENT Husband 16c. DATE (Mo., Day, Yr.) March 4, 2008 d. CEME ERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Service CITY/TOWN Gibbon STATE Nebraska 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, 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: i\NIC IMMEDIATE CAUSE (Final disease or condition resulting In death) a) c o n I APPROXIMATE INTERVAL onset to death Sequentially list conditions, If any, leading to the cause listed on line a. b) DUE TO, OR AS A CONSEQUENCE OF: i cL r4;>.r onset to death • Enter the UNDERLYING CAUSE C) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death d) onset to death 19. WAS MEDICAL EXAMINER OR CORONER �CONTACTED? J) ❑ YES .47p ` 21c. WAS AN AUTOPSY PERFORMED? ❑ YES tl nV 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES LK US 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET 8. NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD in 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) 28b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES �NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Ryan Crouch,D.O., 800 Alpha St., Grand Island, Nebraska 68803 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) 9g. INSIDE CITY LIMITS ® Yes 0 No 17b. Zip Code 68801 1