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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 2/23/2017 LINCOLN, NEBRASKA 201701494 STATE OF NEBRASKA - DEPARTMENT OF HEALTH! AND HUMAN SERVICES CERTIFICATE OF DEATH Cate STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES xiswierftw 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Virginia Marlene Nielsen 4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Kearney, Nebraska 7. SOCIAL SECURITY NUMBER 508 -64 -8365 Sb. FACILITY -NAME (If not IltStitution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island. 68803 9a, RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 2304 West 11th Street 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 Link.) No 15. METHOD OF SPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment nn i_I Removal ❑ Other (Specify) Enter the UNDERLYING CAUSE fdlsease or lnjory:that in(Nated - >. itat events resulting in death) LAST: 20. IF FEMALE: ® Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, hat pregnant within 42 days of death ❑ Not pregnantawt pregnant 43 days to 1 year before death ❑ Unknown if pregnant Within the past year 22a, DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT:WORk7 ❑YES ❑NO 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Tracey Dietz 22b. TIME OF INJURY 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 5a. AGE - Last Birthday (Yrs.) 66 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined CITY /TOWN 2$a. DATE OF DEATH (Mo., Day, Yr.) February 9 2017 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH .l February 10, 2017 09:58 PM O 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) Kenneth Vettel, MD 2 Z 52 re re 6 n a'Q J W O U U o 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES J NO ❑ PROBABLY ❑ UNKNOWN 28a. REGISTRAR'S SR .NATURE 6 5b. UNDER 1 YEAR MOS. DAYS 9e. APT. NO. 26a. HAS ORGAN OR TISSUE s • ATION BEEN CONSIDERED? ❑ YES El NO 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 9f. ZIP CODE 68803 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Ronnie Nielsen 11. FATHER'S -NAME #First; Middle, Last, Suffix) Roger Shiers 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mary Paitz 14a. INFORMANT -NAME Ronnie Nielsen 16b. LICENSE NO. 1328 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) ADfei Funeral Home. 1123 W. 2nd. 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. 21b. IF TRANSPORTATION ❑ Driver /Operator ❑ Passenger ❑ pedestrian 0 Other (Specify) INJURY STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 3. DATE OF DEATH (Mo., Day, Yr.) February 9, 2017 May 4, 1950 6. DATE OF BIRTH (Mo., Day, Yr.) 9g. INSIDE CITY LIMITS' ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT::. Spouse 16c. DATE (Mo., Day, Yr.) February 15, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Westlawn Cemetery Grand Island STATE Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 1>i PART t. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enterterminal events such as cardiac arrest, respiratory arcing, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line.Add additional lines if necessary. IMMEDIATE CAUSE (Final disease or condition resulting IMMEDIATE CAUSE: a) Pneumonia With Respiratory Failure APPROXIMATE INTERVAL onset to death 10 Days .ln;:death) - :.Sequeptially (Itt ncntftiom$ lt any, Molding totire Cause listed': DUE TO, OR AS A CONSEQUENCE OF: b) Stroke onset to death 8 Year DUE TO, OR AS A CONSEQUENCE OF: c) Hypertension onset to death - >10 Years DUE TO, OR AS A CONSEQUENCE OF: d) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®No 21c. WAS AN AUTOPSY PERFORMED? ❑ YES lJ NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED ZIP CODE`' 24b. TIME OF DEATH 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 Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Kenneth Vettel, MD, 2116 W Faidley #400, Box 9802, Grand Islan • Nebraska, 68803 28b. DATE FILED BY REGISTRAR (Mo. ay, Yr.) February 15, 2017