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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 9/27/2016 LINCOLN, NEBRASKA 201607578 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Gge STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES a 4, CC u . W m 1z E' 8 2 O 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Betty Y Struss 4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Oak Nebraska 7. SOCIAL SECURITY NUMBER 506 -30- 5319 8b. FACILITY -NAME (If not Institution, give street and number) Nebraska 'Medicine' 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 13185 West Lochland Rd 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated:: ® Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S. ARMED,FORCES? Give dates of service if Yes. (Yes, No, or Unk.) NO 15. METHOD OF DISPOSITION ® Bunal '❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 20. IP FEMALE: ❑ Not pregnard *)thin pastYear 0 Pregnant at time of death ❑ Notpregnant,,.dut pregnant within 42 days of death ❑ Not pregnant, nut pregnant 43 days to 1 year before death ❑ Unknown H pregnan within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT:W QRKI ❑ YES ,❑ NO 23a. DATE OF DEATH (Mo., Day, Yr.) September13, 2016 Brett Weibel, MD 25. DID TOBACCO USE cONTRIBUTE TO THE DEATH? ❑ YES NC ' ❑ PROBABLY ❑ UNKNOWN 2.8a. : REGISTRAR'S SIGNATURE 5a. AGE - Last Birthday (Yrs.) 89 9b. COUNTY Adams MOS. 9c. CITY OR TOWN Juniata 16a. EMBALMER - SIGNATURE Rebecca L. Brasher 22b. TIME OF INJURY 21e. MANNER OF DEATH ® Natural 0 Homicide 0 Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 23b. DATE SIGNED (Mo., Day, Yr.) September 22, 2016 23c. TIME OF DEATH 09:29 AM w 'z F 3 z a' O I23d. To the best of my knowledge, death occurred at the time, date and place 93 0 , and due to the cause(s) stated. (Signature and Title) • 5b. UNDER 1 YEAR DAYS 8c. CITY OR TOWN OF DEATH (Include Zip Code) Omaha 68198 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home/LTC C] Hospice Facility ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Douglas 9e. APT. NO. 9f. ZIP CODE 68955 3. DATE OF DEATH (Mo., Day, Yr.) September 13, 2016 April28, 1927 6. DATE OF BIRTH (Mo., Day, Yr.) 9g. INSIDE CITY LIMITS ❑ YES ® NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Howard W Struss 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S - NAME (First, Edward Gillen Pearl Nelson Middle, Maiden Surname) 14a. INFORMANT-NAME Miller 16b. LICENSE NO. 1444 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Concordia Cemetery Juniata STATE Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Horne. 209 N. Smith Ave. PO Box G. Kenesaw. Nebraska CAUSE OF DEATH (See instructions and examples) F . PART 1. 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 H necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Hypoxic Arrest disease or condition resulting APPROXIMATE INTERVAL onset to death < 24 Hours <_in death) Sequentially lift conditions, H any leading to the:cause Ilated: on line a. • Enter the UNDERLYING CAUSE tdisease or Injury that initiated the event resulting M death) DUE TO, OR AS A CONSEQUENCE OF: b)Pulmonary Edema DUE TO, OR AS A CONSEQUENCE OF: c) Pulmonary Hypertension onset to death 3 Days onset to death DUE TO, OR AS A CONSEQUENCE OF: d) Pulmonary Fibrosis 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. Acute Cholecystitis 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES El NO 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? 0 Driver/Operator ❑ Passenger ❑ YES ® NO ❑ Pedestrian 0 Other (Specify( USE OF DEATH? RELATIONSHIP TO DECEDENT Daughter 16c. DATE (Mo., Day, Yr.) September 13, 2016 17b. Zip;' Code 68956 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CA ? ❑ YES ❑ NO 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 & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24b. TIME OF DEATH 2 :N r0 U 6 Q N 1 8 w Z 124e. On the basis of examination and /or investigation, in my opinion death occurred at 005 te time, date and place and due to the cause(s) stated. (Signature and Tide) t 24d. TIME PRONOUNCED DEAD 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Brett Weibel MD, 983280 Nebraska Medical Center, Omaha, Nebraska, 68198 28b. DATE FILED BY REGISTRAR (MO. September 26, 2016 Day, Yr.)