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Jaw ISZTI 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 7/27/2016 LINCOLN, NEBRASKA 201'7017 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Give STANLEY S. OOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 8b. FACILITY -NAME (If not institution, give street and number) O CHI Health St Fr„rtcis d m 11. FATHER'S -NAME (Furst, Middle, Last, Suffix) Ralph White 8c. CITY OR TOWN OF DEATH (Include Zip Code) p Grand Island 68803 < 9a, RESIDENCE -STATE stY z Nebraska LL ' 8d. STREET AND NUMBER ,, 308 Church Street 13 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married sv ❑ Married, but separated >g ❑ Widowed ® Divorced ❑ Unknown tto E 13. EVER IN U.S. ARMED FARCES? Give dates of service if Yes. (Yes, No or Unk.) N R 0 1 5. METHOD OF O.ISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Remelts! •❑ Other (Specify) 0. E 0 U d 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Mary Elizabeth Collinson 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Doniphan, Nebraska 7. SOCIAL SECURITY NUMBER 506 -28 -3300 9b. COUNTY Hall Cedarview Cemetery 5a, AGE - Last Birthday (Yrs.) 88 5b. UNDER 1 YEAR MOS. 9c. CITY OR TOWN Doniphan 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ® Eft/Outpatient 0 DOA 16a. EMBALMER - SIGNATURE Chris McCoy DAYS HOURS 8d. COUNTY OF DEATH Hall 9e. APT. NO. 10b. NAME OF SPOUSE (First Middle, Last, Suffix) If wife, give maiden name 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Alta Mae Robinson 14a. INFORMANT-NAME Michael Collinson' 16b. LICENSE NO. 1191 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Doniphan 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Aofel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska CAUSE OF DEATH ass instructions and examples) 18. PART I. Enter the Chain of events -. diseases, injuries, or complications -that directly caused the death. DONOT enter terminal events such as cardiac arrest, Monetary-arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Ventricular Fibrillation disease or condition resulting in death( Sequentially list Conditions, if any, leedingto the cause listed: on line a. Enter the UNDERLYING CAUSE tdiseane or injury that initiat0 . the events resultmt m death) LAST • 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Chronic Renal::Fallure ce W 20. IF FEMALE: ❑: Not pregnailtwithmpaot year V ❑ Pregnant at time of death : .T •❑ Nth pregnant, but pregnant within 42 days of death ❑ Not pregnailt,:but pregnant 43 days to 1 year before death :: -- ❑Unknown itptsgnam within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. . .ORK? ❑ YES NO i DUE TO, OR AS A CONSEQUENCE OF: b) Congestive Heart Failure DUE TO, OR AS A CONSEQUENCE OF: c) 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. 23a. DATE OF DEATH (Mo., Day, Yr.) JU)y 17, 2016 b. GA YE SIUIi/dD (Mo., Day, Yr.) 23c. TIME OF DEATH o ° o July 18, 2016 08:20 AM O {„ W 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. {Specify) CITY/TOWN 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) STATE 24a. DATE SIGNED (Mo., Day, Yr.) 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) Ryan D. Crouch, DO ao- °a z u z O z °� � l C U a 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ 'YES NO 0 PROBABLY ❑ UNKNOWN ❑ YES El NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE /l r 6- avelizgAL 2. SEX Female 5c. UNDER 1 DAY MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 3. DATE OF DEATH (Mo., Day, Yr.) July 17, 2016 6. DATE OF BIRTH (MO. July 19, 1927 9f. ZIP CODE 68832 July 22, 2016 STATE Nebraska onset to death Minutes onset to peat Chronic onset to death onset to deat • 24b. TIME OF DEATH 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) Day, Yr.I ❑ Hospice Facility 9g. INSIDE CITY LIMITS II YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Son 16c. DATE (Mo., Day. 17b, Zip code 68801 APPROXIMATE sINTERVAL 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ❑ Na 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO ZIP CODE c. PRONOUNCED CZ:iD (.rii.., Day,': r.) 24d. TIME ?RONo b.-.:D DEAD 28b. DATE FILED BY REGISTRA July 21, 2016 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO