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�. t i Ya Y STATE OF NEBRASKA WHEN THIS r' 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 6/21/2016 LINCOLN, NEBRASKA 201701865 STANLEY S. COPER ASSISTANT S AT E REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Faye Arlene Peterson 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Horace Township,:' Nebraska 7, SOCIAL SECURITY NUMBER 506-20-3919 tY $b. FACILITY -NAME (If not Institution, give street and number) a 8 CHI Health St. Francis W lY 8c. CITY OR TOWN OF DEATH (Include Zip Code) a _ Grand Island 68803 9 a. RESIDENCE-STATE U Nebraska LL 9d. STREET AND NUMBER 418 White Avenue ID 10a. MARITAL STATUS AT TIME OF DEATH Married 0 Never Married � Q Marrietl, but separated ®Widowed 0 Divorced 0 Unknown 13. EVER IN U.S.:ARMED FORCES? Give dates of service if Yes. y (Yes, No, or Link.) No sut . 1- 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal 0 Other (Specify) ut g 20. IF FEMALE: ❑ Not pregnant wtthin 854t year W ❑ Pregnant at time of death ❑ NOS pregnant, but pregnant within 42 days of death • . .C2. 0 Not pregnant; but pragtiarl 43 days to 1 year before death W ❑ Unknown if pregnant within the past year E 22a. DATE OF INJURY (Mo., Day, Yr.) 0 22d,. INJURY AT WORK? . t ❑ YES: ,] NO 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. 23a. DATE OF:DEATH (Mo., Day, Yr.) J.111 9 2016 2S. 0(D TOBACri0 U$E CONTRIBUTE TO THE DEATH? YES -® NO L ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print 5a. AGE - Last Birthday (Yrs.) 9 9b. COUNTY Hall 16a. EMBALMER-SIGNATURE Not Embalmed 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH June 10, 2016 04:55 PM 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Larry L. Hansen, MD 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑Could not be determined CITY /TOWN Larry L Hansen, MD, 3016 West Faidley, Grand Island, Nebraska, 68803 f 28a::RISTRAWS$TURE 41. 5b. UNDER 1 YEAR MOS. 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES NO DAYS 9e. APT. NO. 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 9f. ZIP CODE 68803 3. DATE OF DEATH (Mo., Day, Yr.) June 9, 2016 6. DATE OF BIRTH (Mo. Day, Yr,) December 26, 1924 8a. PLACE OF DEATH HOSPITAL © Inpatient �] ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand' Island' 9g. IN$IDE CITY LIMITS::: YES O NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Pearl E Peterson 11. FATHER'S -NAME (First, Middle, Last, Suffix) °' Silas Morrow 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Edith Madison 14a. INFORMANT -NAME Victory Peterson 1613.' LICENSE NO. 14b. RELATIONSHIP TO DECEDENT Daughter 16c. DATE (Mo., DayYr) June 13, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY I TOWN Gibbon STATE Nebraska 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 (See instructions and examples) 18. PART I. Enter the chair of events -- diseases, injuries, or complications -that directly caused the death. DO NOT enterterminal events such as cardiac arrest, respiratory arrest, of ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. 17b. Zip'Code 68801 IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Pulmonary Emboli dissase er condition resueic3 in death) Sequkntially list gtlltditipns, it any reading to the Cause hated on line e. Enter the UNDERLYING CAUSE ;(disease or injury that initiated the eslentsresuautg in death) • • LAST:: DUE TO, OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: C) 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. Atrial Fibrillation, Seizure Disorder, Colon Cancer A PP ROXIMATB.INTERVAL onset to death 24 Hrs onset to death: onset to death onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES E NO 2b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian O Other (Specify) STATE 24a. PATE SIGNED (Mo., Day, Yr.) 21c. WAS AN AUTOPSY PERFORMED? ? " ❑ YES NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO I 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc, (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 24b. TIME OF DEATH ZIP CODE 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(a) stated (Signature and Title) 26b. WAS CONSENT GRANTS Not Applicable if 26a is NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) June 15, 2016