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,ItFalNei � %v lllflria .�' „■" ;1`i \'Ykhi, datodit ■ui} STATE OF NEBRASKA 1 gicter Cl 0 AO Iffllgt 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 201702482 4/12/2017 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Louise Milby 4, CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Martinez, California 7. SOCIAL SECURITY NUMBER 552 -42 -2906 $b. FACILITY -NAME (If not Institution, give street and number) Golden LivingCenter -Grand Island Lakeview 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8 a. RESIDENCE -STATE 9b. COUNTY Nebraska Hall 9d. STREET AND NUMBER 1703 S. Ingalls 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Robert Hansken 14. EVER IN U.S..ARMED ; F.ORCES? Give dates of service if Yes. (Yes, No, or uik.) NO 15. METHOD OF DISPOSITION Burial •• ❑ Donation Not Embalmed El Cremation ❑ Entombment ❑ Retrioval ;:❑ Other (Specify) 17a, FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street, Grand Island. Nebraska for Central Nebraska Cremation & Mortuary Service. 609 Front Street. PO Box 280. Gibbon. Nebraska CAUSE OF DEATH See instructions and exam des IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Arrest disease or condition resulting in death) ... Sequentially fist conditions, if any leading to ute cause listed DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE ) Pulmonary Hypertension (disease drinjury tiiat initiete4 Ate events tesuiting in death) DUE TO, OR AS A CONSEQUENCE OF: LA" d) Diastolic Heart Failure 20. IF?FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Mot pregnant,; but pregnant within 42 days of death ❑ Not pregna,,, , out pre days to 1 year before death ©Unknewrl it p within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d.1NJURY AT WORK? DYES ❑NO 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY /TOWN 3a DATE OF:DEATH (Mo., Day, Yr.) AUdu$t 7,<:2013 3b DATE SIGNED (Mo., Day, Yr.) August 8, 2013 16a. EMBALMER-SIGNATURE DUE TO, OR AS A CONSEQUENCE OF: b)Obstructive Lung Disease 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 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) Michael A. Donner, MD 23c. TIME OF DEATH 10:30 PM 5a. AGE • Last Birthday (Yrs.) 14a. INFORMANT-NAME Charles Blazer Milby 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services 81 8a. PLACE OF DEATH HOSPITAL 0 Inpatient ❑ ER/Outpatient ❑ DOA 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 5b.; UNDER , 1 YEAR MOS. DAYS 9c. CITY OR TOWN Grand Island Pedestrian ❑ Other (Specify) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES RI NO ❑ PROBABLY ❑ UNKNOWN ❑ YES til NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Michael A. Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 1 28a.REGISTRAR'S SIGNATURE E )fcJ V� /(- /"__ a.�/egp wr+i _ 9e. APT. NO. ab. LICENSE NO. STANLEY S. OPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE' OF DEATH 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. OTHER E Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall CITY I TOWN Gibbon 24a.iDATE:SIGNED (Mo., Day, Yr.) 9f. ZIP CODE 68803 3. DATE OF DEATH (Mo., Day, Yr.) August 7, 2013 6. DATE OF BIRTH (Mo Day, Yr.) August 22 1x331 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Charles Blazer Milby 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Paulene Engleman 18. PART 1. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. 00 NOT enter terminal events such as cardiac arrest, fespiratory arrest, of Ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Chronic, Kidney Disease 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 14b. RELATIONSHIP TO DEO Spouse 16c. DATE (Mo., Day, Yr.) August 8, 2013 STATE Nebrasl 17h. Zip Code 68801 6884Q onset to death Immediate onset to::death: Years onset to death Years onset to de ath Years 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? 0 Oliver /Operator ❑ YES El NO ❑ Passenger 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24d. TIME PRONOUNCED DEAQ 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) 1 9g. INSIDE CITY LIMITS ® YES ❑ NO APPROXIMATE INTERVAL DENT 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? :. ❑ YES ❑ NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.} August 9, 2013