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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 3/21/2017 LINCOLN, NEBRASKA 201702322 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES C.) w W 11. FATHER'S - NAME {First, , Gerald Russell a E 0 ._ .._ dl .0 I- 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Debra Lee McWilliams 4. CITY D STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Lincoln, Nebraska 7. SOCIAL SECURITY NUMBER 506-72-3661 8b. FACILITY•NAME (If not Institution, give street and number) 4302 Claussen Road 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9e. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 4302 Claussen Road 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 Unk.) No 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment Removal ; 0 Other (Specify) " d) 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? DYES ❑NO Middle, Last, Suffix) 16a. EMBALMER - SIGNATURE Not Embalmed 9b. COUNTY Hall 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) ADfel Funeral Home. 1123 W. 2nd. Grand Island, Nebraska tb. PAA t i. EMef the'chain of events - -diseases, injuries, or complications -that directly caused the. death. DO NOT enter terminal events such as cardiac arrest, reap uater arrest, orveetricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause end lino. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Acute On Chronic Hypercarbic Respiratory Failure disease or condition resulting TO death) Sequeritiallyfist cCnditions if any, leading to the eattse astetl on lirrea. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE. c) (disease orin(uryfliat indiaied -. the events resdttn death) DUE TO, OR AS A CONSEQUENCE OF: WST:'s So. DATE OF DEATH (Mo., Day, Yr.) Februafy 23 2017 3b. DATE SIGNED (Mo., Day, Yr.) February 27, 2017 DUE TO, OR AS A CONSEQUENCE OF: b)COPD With Emphysema 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Hypothyroid, Factor .V Leiden, Prosthetic Aortic Valve For AS, History Of Hodgkins Disease:1978,History Of West Nile Virus 20. IF FEMALE: Not pregnant'within past year ❑ Pregnant at time of death Not pregnant, but pregnant within 42 days of death Not pragriefiL but pregnant days to 1 year before death ❑ Upknowe if pregnant within the past year 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. b ,Z 5 F g 0 Z 8 g - 1 0 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) s KimberlvA, Mcke)s; MD CAUSE OF DEATH (See instructions and examples) 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ suicide ❑ Could not be determined 23c. TIME OF DEATH 07:25 PM 25. DID TOBACCO USECONTRIBUTE TO THE DEATH? to YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 5a. AGE - Last Birthday (Yrs.) 64 � 28a. REGISTRARS SIGNATURE / /� - „ - 5b. UNDER 1 YEAR MOs. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY' OR TOWN. Grand Island 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 0 NO 27, NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Kimberly A Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 DAYS 9e. APT. NO. 2. SEX Female 5c. UNDER 1 DAY HOURS Gibbon CITY /TOWN STATE MINS. OTHER ❑ Nursing H ® Decedent' ❑ Other (Spl 8d. COUNTY OF DEATH Hall CITY / TOWN 9f. ZIP CODE 68803 Suffix) If wife, g 10b. NAME OF SPOUSE (First, Middle, Last, Henry McWilliams 1 12. MOTHER'S -NAME (First, Middle, Maiden Alta Copper 14a. INFORMANT -NAME Henry McWilliams 16b. LICENSE NO. 2113. IF TRANSPORTATION INJURY ❑ Otiver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 245. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 3 0 21d. WE TO 0 24b. 24d. 24e. On the basis of examination and/or investigation, in the time, date and place and due to the cause(s) s 26b. WAS CON Not Applicable if March 3, 20 . DATE OF DEATH (Mo., Day, Yr.) February 23, 2017 6. DATE OF BIRTH (Mo. Day, Yr,) July 13 1952 me/LTC ❑ Hospice Facility Home :ify) ive maiden na Surname) 9g. INSIDE CITY LIMITS YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) February 27, 2017 STATE Nebraska 17b, Zip *Code 68801 APPROXIMATE >INTERVAL onset to death Years onset to Slea th. Years onset to death onset to d 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? 0 YES ® NO 21c. WAS AN AUTOPSY PERFORMED? YES 0 NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) RE AUTOPSY FINDINGS AVAILABLE COMPLETE CAUSE OF DEATH? ❑ NO TIME OF DEATH TIME PRONOUNCED DEAD my opinion death occurred at `. ted. (Signature and Title) GENT GRANTED? 26a is NC) ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mo Day, Yr.) 17