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N l e. .lR l! :. t .. w,. STATE OF NEBRASKA 644,, x. R ♦.i;�1 TXhT t,f,t9/� s.. N/I W HEN THIS ' ' COPY CARRIES THE RAISED SEAL 'OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO 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 1/30/2017 BE A TRUE COPY OF THE ORIGINAL RECORD 201700808 LINCOLN, NESRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND, HUMAN SERVICES CERTIFICATE OF DEATH A awl STANLEY S. DOOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERV ICES esimeier 0 w 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Nancy Louise Fruchtl 4, CITy STA`L`E Ott TERRITORY, OR FOREIGN COUNTRY OF BIRTH Reading, Pennsylvania 7. SOCIAL SECURITY NUMBER 176- 26-3975 8b. FACILITY - NAME (If not Institution, give street and number) CHI Health St. Francis 9a. RESIDENCE-STATE z Nebraska LL 9d. STREET AND NUMBER EGISTRARS 906 E. Delaware (disease or that Initiated Abe events i *Litho in death) LAST 23a. DATE OF DEATH (Mo., Day, Yr.) JanuaN 19z 2017 3b. DATE SIGNED (Mo., Day, Yr.) January 20 2017 2 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Richard Fruehlinq, MD a. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES El NO El PROBABLY ❑ UNKNOWN 9b. COUNTY Hall 23c. TIME OF DEATH 07:43 PM 5a. AGE - Last Birthday (Yrs.) 80 SIGNATURE �- Cotroar"- 5b. UNDER 1 YEAR MOS. 9c. CITY OR TOWN Grand Island DAYS 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9e. APT. NO. 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES II NO 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 9f. ZIP CODE 68801 3. DATE OF DEATH (Mo., Day, Yr.) January 19, 2017 6. DATE OF BIRTH (MO., Day, Yr.) June 27, 1936 8a. PLACE OF DEATH HOSPITAL © Inpatient El ER/Outpatient ❑ DOA OTHER ❑ Nursing Home/LTC ❑ Hospice Facility El Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 28b. DATE FILED BY REGISTRAR (M January 24, 2017 9g. INSIDE CITY LIMITS Gil YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Lewis J Fruchtl Middle, Last, Suffix) If wife, give maiden name 11. FATHER'S -NAME (First, Middle, Last, Suffix) Louis Twardowski 12. MOTHER'S -NAME (First, Helen Chelius Middle, Maiden Surname) 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME (Yes, No, or Unk,) No Lewis J Fruchtl 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPO$LTION ❑ Burial ❑ Donation ® Cremation ❑ Entombment 16a. EMBALMER- SIGNATURE Not Embalmed 16c. DATE (Mo., Day, Yr.) January 20, 2017 0 Removal ; Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE Nebraska 17a. FUNERAL NOME NAME AND MA LING ADDRESS (Street, City or Town, State) Curran Funeral Chapel. 3005 S. Locust St.. Grand Island. Nebraska 1 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 15• 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: IMMEDIATE CAUSE (Final a)Acute Myocardial Infarction With Cardiac Arrest disease or condition resulting APPROXIMATE'INTERVAl, > onset to death 1 Hour SegUentially fiat conditions, H any, leading Rothe cause listed on line DUE TO, OR AS A CONSEQUENCE OF: b) Enter the UNDERLYING CAUSE DUE TO, OR AS A CONSEQUENCE OF: C) onset to death DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES gl NU 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death 0 Not pregnant. put pregnant within 42 days of death ❑ Not pregnant . !but pregnanik 43 days to 1 year before death ❑ tinknlWit if pregnant Within the past year 21a. MANNER OF DEATH El Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ (laver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) I 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? C:1 YES [INC) � 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 investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Tide) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑:.YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Richard Fruehiing.; MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 `Day;