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STATE OF NEBRASKA WHEN THIS COPY CARthES THE RAISED SEAL OF THE NEBRASKA HEALTH AHD HLi.MAM 1 $ERWICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL, AECORD pN pi,,c4VITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS WITCH; IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. 201.508095 DATE OF ISSUANCE 201700 ? NOV 0 8 2007 rr : , �p LINCOLN, NEBRASKA"HEALT'AAID HUMAIII $EE`IVIPES ' STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN gERylCtsFIN Eii4NDS FIT'- CER TIFICATE OF DEATH . , . r a 7 33 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Beverly Joan Ostrander 2.1EX - Ferri*, . 3.D/l QFDEATH (Mo, Day, Yr.) 'October 25, 2007 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Central City, Nebraska 5a. AGE -Last Birthday (Yrs.) 73 5b. UNDER 1 YEAR Sc..UNDER DAY - 6. DATE OF BIRTH (Mo., Day, Yr.) June 7, 1934 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -36 -1464 8a. PLACE OF DEATH HOSPITAL: ❑ Inpatient MR ❑ Nursing Home /LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not institution, give street and number) 315 N. Washington St. ❑ ER /Outpatient ® Decedents Home ❑ Doe 0 Other(Specify) To Be CompletedNerified by: FUNERAL DU 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall ga. RESIDENCE-STATE Nebraska fib. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER - 315 N. Washington St. 9e. APT. NO 9LZIPCODE 68801 9g.INSIDE CITY LIMITS Gd YES ❑ NO t0a. MARITAL STATUS AT TIME OF DEATH al Married ❑ Never Marned ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wile, give maiden name. Donald Ostrander 11. FATHER'S -NAME (First, Middle, Last, Suffix) Leslie William Martin 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Nina Grace Dughman 13. EVER IN U.S. ARMED FORCES? Give dates of service ilyes. (Yes, no, Drunk.) No 14a. INFORMANT-NAME Donald Ostrander 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION 23 Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal 0 Other (Specity) ' 16a. ' BALMER-SIGNAT _ J O , /`�Asfi 16b. UCENSE NO. /a 7/ 16c. DATE (Mo., Day, Yr. ) October 30, 2007 16d. CEMETERY, CREMATORY OR OTHER LOCA' CITY I TOWN STATE Westlawn Memorial Park Grand Island Nebraska 17a FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City orTown, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, N ebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions lea To Be Completed by: CERTIFIER 18. PART I. Enter the chain of events - diseases, Injuries, or complications -that directly caused the death. DO NOT enter rch as ;ar:Lac arrest, "T AF 'ROXIM. c . - ?AL respiratory arrest, or ventricular fibrillation without showing the ecology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. IMMEDIATE CAUSE: onset to death ` J (-N p t^ IMMEDIATECAUSE(Falai (a) N C'1 C\ ( Q s W k "k V disease or candtlenresuting DUE TO, OR AS A CON ENCE OF: 1 onset to death In death) Sequentially list conditions, II 04 any, leading to themes listed DUE T0, OR AS A CONSEQUENCE OF. I onset to death on line a. Enter the UNDERLYWGCAUSE (disease or Injury that Initiated ( the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: f onset to death LIL4T (d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART I. ^ / C e u 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED' 0 YES tif NO 20. IF FEMALE: *Not pregnant within past year Q Pregnant at time of death ❑ Not pregnant, but pregnant within 42 rays of death 0 Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown If pregnant within the past year 21a, MANNER OF DEATH eturel ❑ Homicide 0 AccidentQ Pending Investgaton ❑ Wade ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑Driver /Operator ❑ Passenger ❑ Pedestrian ❑Other (Spedty) 21c WAS AN AUTOPSY PERFORMED? ❑ YES �NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES A , n' - r '(t 717 1 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 22c. PLACE OF INJURY-At home, farm, street, factory, office building, constnlcto 22d.INJURYATWORK? ❑ YES Q NO 22e. DESCRIBE HOW INJURY OCCURRED N0V 3 0 210 s 22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE r VLA'DE To be completed by Attendlnp PHYSICIAN ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) 10- ).--A-. O y M 24a, DATE SIGNED (Mo., Day,Yr.) 24b.TIME OF DEATH m 23b. DATE SIGNED (Mo., Day, Yr.) - O 23c. TIME OF DEATH 'BS m v 0 a � a.< 24c. PRONOUNCED DEAD (Mo., Day,Yr.) 24d. TIME PRONOUNCED DEAD m 23d.To the best of my knowledge, death occurred at Inc time, date and place 8 w z O 24e. On the basis of examination and /or investigation, in my opinion death occurred at end Qfre to the causes stated. (Signature and Title) • .o 0 8 the time, date and place and due to the cause(s) stated. (Signature and Title ) � Z�nk.\\ L MO ;21 8 a 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY \ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED ❑ YES Y, 3LO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES ❑ 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type orPnnt) John Cannella, M.D., 729 N. Custer, Grand Island, NE 68803 i ii• 28a. REGISTRAR'S SIGNATURE r / � /J � 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) NOV 5 2007 STATE OF NEBRASKA WHEN THIS COPY CARthES THE RAISED SEAL OF THE NEBRASKA HEALTH AHD HLi.MAM 1 $ERWICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL, AECORD pN pi,,c4VITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS WITCH; IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. 201.508095 DATE OF ISSUANCE 201700 ? NOV 0 8 2007 rr : , �p LINCOLN, NEBRASKA"HEALT'AAID HUMAIII $EE`IVIPES ' STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN gERylCtsFIN Eii4NDS FIT'- CER TIFICATE OF DEATH . , . r a 7 33