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Yr/40041k, ' '..44,9101‘k iiitiA4V40 STATE OF NEBRASKA 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 4/25/2016 LINCOLN, NEBRASKA 201607363 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Hazel Joan Risden 0 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation Cremation ❑ Entombment ❑ Removal 0 Other (Specify) 4. CITY; AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Ulysses, N ebra5 k• 7. SOCIAL SECURITY NUMBER 507 -32 -7967 8b. FACILITY -NAME ilf not Institution, give street and number) 6Y r; CHI Health St. Francis ix 8c. CITY OR TOWN OF DEATH (Include Zip Code) • Grand Island 68803 g 9 a. RESIDENCE -STATE Nebraska W 9d. STREET AND NUMBER 360 Redwood Rd ▪ 1Qa. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married m ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown E 13. EVER IN U.S.; ARMED FORCES? Give dates of service if Yes. (Yes, No or Link.) NO a E 0 41 22d ( NJURY AT I,NORK? 22e. DESCRIBE HOW INJURY OCCURRED F' ' ' !❑YES 'i0 NO 23a. DATE OF DEATH (Mo., Day, Yr.) Ap rtl II' 2016 23b. DATE SIGNED (Mo., Day, Yr.) April 13. 2016 9b. COUNTY Hall 16a. EMBALMER- SIGNATURE Not Embalmed .R w O W J 1 V Z 0 3d. To the best of my knowledge, death occurred at the time, date and place .8 o and due to the cause(s) stated. (Signature and Title) 30 ri Trams S. NaQeman, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? D YES to NO ❑ PROBABLY ❑ UNKNOWN 28a...REGISTRA34 SIGNATURE 23c. TIME OF DEATH 02:25 PM 5a. AGE - Last Birthday (Yrs.) 85 5b. UNDER 1 YEAR MOS. DAYS HOURS 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 8d. COUNTY OF DEATH Hall 9e. APT. NO. 2. SEX Female 5c. UNDER 1 DAY 1 Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Darwin John Risden m d 11. FATHER'S -NAME {First, Middle, Last, Suffix) Leslie Stine 1 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Dorsey Blacketer 14a. INFORMANT -NAME Darwin John Risden '< 16b_ LICENSE NO. 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon STATE Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska 24a. DATE SIGNED (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES To NO MINS. 4c. PRONOUNCED DEAD (Mo., Day, Yr.) 9f. ZIP CODE 68803 3. DATE OF DEATH (Mo., Day, Yr.) April 12, 2016 6. DATE OF BIRTH (Mo. July 9, 1930 9g. INSIDE CITY L}MITS' ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Husband 16c. DATE (Mo., Day, Yr.) April 13, 2016 24b. TIME OF DEATH 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 1 Sequantially fist conditions, it any, leadingte theieauie lisfed on line a. Enter the UNDERLYING CAUSE (disease orinjury:that inlhate 1 .... ._ ._.. - _ _.... • the,eyeins •resulriig in death). LAST` DUE TO, OR AS A CONSEQUENCE OF: b)Metastatic Adenocarcinoma Pancreas '< DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death 'tY ' • ,20. IF r FEM A LE; K ❑ Not pregnant within past year W ❑ Pregnant at time of death U Not •pregnant,:but pregnant wit of death ❑ Not pre tlut pregnant43 days hin 42 to days 1 year before death ❑ Unknown if pregnatitwithin the past year 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined but not resulting in the underlying cause given in PART I. onset to oeatb• Weeks onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES I NO 2111. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED ? :: ❑. Driver /Operator 0 YES E NO ❑ Passenger ❑ Pedestrian ❑ Other(Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ?;, ❑ YES ❑ NO 18. PART I. Enter the sham of events - - diseases, injuries, or complications -that directly caused the death. DONOT enterterninal events such as cardiac arrest, respiratory arrest, Or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one eause' a Time Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Streptococcus Sepsis disease or condition resulting APPROXIMATE I NTERVAL onset to death 2 Days 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 122c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE 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) 24d. TIME PRONOOUN DEAD 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 1 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Travis S.; MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 _ "r"' 28b. DATE FILED BY REGISTRAR(NM., Day, Yr.) April 19, 2016