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r.+n�`i1rY.t� > ast' Sys.. a f. ... ,.a, , _. 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 10/13/2016 LINCOLN, NEBRASKA V SS S ANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH ate 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Lila Irene Hiller 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Bellwood, Nebraska 7. SOCIAL SECURITY NUMBER 508 -32 -1628 8b. FACILITY -NAME (If not Institution, give street and number) Tiffany Square Care Center ce 8c. CITY OR TOWN OF DEATH (include Zip Code) Grand Island 68$03 .9a. RESIDENCE -STATE Nebraska LL 9d. STREET AND NUMBER a 2115 lndependence Avenue it 10a. MARITAL STATUSAT TIME OF DEATH ❑ Married ❑ Never Married ❑ •Married, but separated ® Widowed ❑ Divorced ❑ Unknown • 11. FATHER'S -NAME (First, Middle, Last, Suffix) Otto John Selzer Sr CAUSE OF DEATH (See instructions and examples) Enter t P of e .._ _. _.. B. ,M1RT i. lie'cham of events-diseases, injuries, or complications -that directly caused the death. D0 NOT enteraerminal events such as cardiac arrest, respiratory areal, or ventric dar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Pneumonia APPROXIMATE INTERVAL 1 Week ECQL 13. EVER IN U.S ARMED FORCES? G 43 (Yes, No, or Unk.) NO ive dates of service if Yes. • 15. METHOD O F 131SPOSI F ® Burial ❑ Donation ❑ Cremation ❑Entombme ❑,Removal ;❑ Othe r.(Spec ify ) Enter the. UNDERLYING CAUSE (d isease er injury that initiated tarn in death) RE SIGNAT Sa. AGE - Last Birthday (Yrs.) 92 9b. COUNTY Hall MOS, 16a. EMBALMER - SIGNATURE Laurie D. Sheffield 23a. DATE OF DEATH (Mo., Day, Yr.) September 27, 2016 23b. DATE SIGNED (Mo., Day, Yr.) September 29, 2016 n S F n • w J 5 O z 0 z 3d. To the best of my knowledge, death occurred at the time, date and place ig o and due to the cause(s) stated. (Signature and Title) o John A. Wagoner, MD 23c. TIME OF DEATH 11:25 PM 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print John A. Wagoner,; MD, 800 N Alpha Street, Grand Island, Nebraska, 6 5b. UNDER 1 YEAR 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA OTHER ® Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 9c. GITY OR TOWN Grand island DAYS HOURS 8d. COUNTY OF DEATH Hall 9e. APT. NO. 2. SEX Female 5c. UNDER 1 DAY MINS. 9f. ZIP CODE 68803 3. DATE OF DEATH (Mo., Day, Yr.) September 27, 2016 6. DATE OF BIRTH (Mo September 27, 1924 Day, Yr.) 9g. INSIDE CITY LIMITS ® YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Paul Peter Hiller d a, 12. MOTHER'S-NAME (First, Middle, Maiden Surname) Lucile Magdolena Koenig 14a. INFORMANT- NAME Pamela Glaser 16b. LICENSE NO. 1397 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska 14b. RELATIONSHIP TO DECEDENT Daughter 16c. DATE (Mo Day Yr.) October 3, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION Sts. Peter & Mary Catholic Cemetery CITY / TOWN Bellwood STATE Nebraska In death) Senuentiahy iet sondlt,ons, if i any) :(eeding to the cause listed on line a. ... DUE TO, OR AS A CONSEQUENCE OF: b) Emphysema onset to •'' 10 Years DUE TO, OR AS A CONSEQUENCE OF: C) the e ye L AST DUE TO, OR AS A CONSEQUENCE OF: d) Onset to death 18, PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Dementia 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES EI NO re W (.2 20. iFFEMALEt .. ❑ Not pregnarrtwithin 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 ❑ Unknewn it pregnantwifhiti the past year 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger 0 Pedestrian Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH . ❑ YES ❑ NO E 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) N . Fd d, INJURY AT WORK ?. OYES ❑ 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET& NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD 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(*) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS OR ❑ YEs l NO ❑ PROBABLY ❑ UNKNOWN ❑ YES N OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? tz NO Not Applicable if 26a is NO ❑YES ❑ NO 28b. DATE FILED BY REGISTRAR (MO October 7, 2016