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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 11/9/2016 LINCOLN, NEBRASKA 20160 771 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Lillian De phine Stobbe 4. CITY: AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Ashton, Neb raska � 7. SOCIAL SECURITY NUMBER 507 -24 -2085 8b FACILITY -NAME (if not Institution, give street and number) ce a 712 "West 13th Street 8c. CITY OR TOWN OF DEATH (Include Zip Code) c Grand Island. 68803 9e RESIDENCE -STATE Nebraska 9b. COUNTY Hall z - E 9d. STREET AND NUMBER 712 West 13th Street a a3 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated ®Widowed 0 Divorced 0 Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) S o John Peters a ` 13 EVER IN U.S. ARMED FORCES? Give dates of service if Yes. G 1 1 � (Yes, Na, or Urik.) No cwi 15. METHOD OF DISPOSITION E Burial 0 Donation ❑ Cremation ❑ Entombment 0 Removal 0 Other (Specify) is. H ce Lu W V I O. if FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death © (lot pregnant,:hut pregnant A3 days to I year before death ❑Unk nown itpregnantwishlnthe past year E 22a. DATE OF INJURY (Mo., Day, Yr.) cf 22&.INJURY ATWORK? ]yes ONO • 22b. TIME OF INJURY 23a. DATE OF DEATH (Mo., Day, Yr.) 5•October 23i2016 23b, DATE SIGNED (Mo., Day, Yr.) 23t. TIME OF DEATH � 7» a F el z October 26, 2016 09:22 PM u a O 3d. To. the best of my knowledge, death occurred at the time, date and place g G and due to the cause(s) stated. (Signature and Title) Micha A. Donner, MD 25. trip TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES E NO ❑ PROBABLY ❑ UNKNOWN 5a. AGE - Last Birthday (Yrs.) 90 16a. EMBALMER- SIGNATURE Gwen K. Hvronemus 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 5b. UNDER 1 YEAR MOS. 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ENO DAYS 9e. APT. NO. 2. SEX Female . PART I. Enter the Chain of euspts -- diseases, injuries, or complications -that directly caused the death, DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventritutar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause an a line. Add additional lines H necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting APPROXIMATEINTERVAL onset to death Immediate 5c. UNDER 1 DAY HOURS 24a. DATE SIGNED (Mo., Day, Yr.) MINS. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC E Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 21b. IF TRANSPORTATION INJURY Driver /Operator ❑ Passenger Pedestrian O otlter(Specify) 9f. ZIP CODE 68803 14a. INFORMANT -NAME Sheila Krolikowski 16b. LICENSE NO. 1448 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livinaston- Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Intractable Back Pain, Patient And Family Transition To Hospice Care 3. DATE OF DEATH (Mo., Day, Yr.) October 23, 2016 6. DATE OF BIRTH (Mo., Day, Yr.) November 25, 1925 28b. DATE FILED BY REGISTRA November 1, 2016 9g. INSIDE CITY LIMITS YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Stobbe 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mary Jasnoch 14b. RELATIONSHIP TO DECEDENT Daughter 16c. DATE (Mo., Day, Yr.) October 28, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN Westlawn Memorial Park Cemetery Grand Island STATE Nebrask 17b, Zip Code 68803 CAUSE OF DEATH (See instructions and examples) in death) .. Sequentially list cfi if any, leading to the cause listed on lines _.... __:. DUE TO, OR AS A CONSEQUENCE OF: b) Intractable Back Pain Enter the UNDERLYING CAUSE (eiseastf erinjurytFat imtiated:. DUE TO, OR AS A CONSEQUENCE OF: C) Ring in death) the events LAST:: DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? DYES ENO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? El yes 0 N 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. CITY /TOWN STATE ZIP CODE 24b. TIME OF DEATH 34c. PRONOUNCEr DEAn (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and /or investigation, in my opinion death occurred' 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 ❑ NO 1 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Michael A. Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR`S SIG � 5 NATURE o ot , Day, Yr.) b. Giro STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES