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STATE OF NEBRASKA 9 h .0 1. DECEDENTS - NAME (First, Middle, Last, Suffix) Letha Ann Brooks 4 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 1/9/2017 LINCOLN, NEBRASKA CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Creighton, Nebraska 7. SOCIAL SECURITY NUMBER 507 -96- 7343 b. FACILITY -NAME (If CHI Health St. n Inds titution, give street and number) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9 a♦ RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 4117 Mason Ave 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married I 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name: ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Michael Ernest Brooks 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Robert Kruger Mary Joanne Angus 1$. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME (Yes, No, or Unk.) No Michael Ernest Brooks 5. METHOD OF DISPOSITION ❑ Burial ❑ Donation I Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island. Nebraska 1s. PART I. Enter the chain of eVeits -- diseases, injuries, or complications -that directly caused the. death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricutar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE (Final a) Cardiac Arrest disease or condition resulting in, death) sequentially not conditions, if any, leading to the cause listed . on line' a. Enter the UNDERLYING CAUSE (d isease or injury that initiated the events resultrg in death) LAST 18 PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 20. IF FEMALE: s ® Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death 0 Not pregnant but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 2t1. INJURY AT WORK? ] YES O NO 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Not Embalmed IMMEDIATE CAUSE: DUE TO, OR AS A CONSEQUENCE OF: b) Sepsis DUE TO, OR AS A CONSEQUENCE OF: c) )schemic Bowel DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. a. DATE OF DEATH (Mo., Day, Yr.) December 26, 2016 23G, DA :Pe 5i4../(4r l3 (lr•w., uay, . 11.1 LJ4 rilylE VF ri Cla I ri December 28, 2016 10:08 AM 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) Chad Vieth, MD 28a. REGISTRAR`S SIGNATURE STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 201700886 5a. AGE - Last Birthday 5b. UNDER 1 YEAR (Yrs.) 52 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services CITY/TOWN 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA Sc. CITY OR TOWN Grand Island 9e. APT. NO. CAUSE OF DEATH (See instructions, and examples) 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined MOS. I NO DAYS 1 16b, LICENSE NO. Gibbon 2. SEX Female HOURS 24a. DATE SIGNED (Mo., Day, Yr.) 5. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES E NO ❑ PROBABLY ❑ UNKNOWN ❑ YES 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 5c. UNDER 1 DAY A Coe MINS. March 8, 19 OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) I 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68803 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) STATE onset to,dea Hours onset to death Days 24b. TIME OF DEATH 1,,. ..e w wnnE 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) 3. DATE OF DEATH (Mo., Day, Yr.) December 26, 2016 6. DATE OF BIRTH (Mo.,; Yr.) ❑ Hospice Facility 9g. INSIDE CITY LIMITS E, YES ❑ NO 14b. RELATIONSHIP TO DECEDENT::. Husband 16c. DATE (Mo., ABy; Yr.) December 29, 2016 STATE Nebraska 17b. Zip Code ?. 68801 APPROXIMATE:: INTERVAL.. onset to death Minutes 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc, (Specify) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDING AVAILABLE. TO COMPLETE CAUSE OF DEATH ?: ❑ YES ❑ NQ `ZIP CODE 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ Yi S ❑ N0 28b. DATE FILED BY REGISTRAR (MC., December 30, 2016