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To Be CompletedNerified by: FUNELLliIREGf6R 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Jeanne Marie Chandler 2. SEX' Female 3. DATE OF DEATH (Mo.,Day,Yr.) October 11, 2008 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH St. Paul, Minnesota 5a. AGE -Last Birthday (Yrs.) 69 6b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) MOS. DAYS HOURS MINS. March 3, 1939 7. SOCIAL SECURITY NUMBER 469-40 -3780 8b. FACILITY -NAME (If not Institution, give street and number) 205 West 21st Street 8a. PLACE OF DEATH HOSPITAL: ° Inpatient OTHER:[ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient $i Decedent's Home ❑ DOA ° Other(Speclfy) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 ad. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 913. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 205 West 21st Street 90. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® Yes ❑ No 10a. MARITAL STATUS AT TIME OF DEATH BD Married ❑ Never Married 0 Married, but separated ❑ Wldowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Fred William Chandler 11. FATHER'S -NAME (First, Middle, Last, Suffix) John 0 Sather 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Thelma Hanson 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or unk.) No 14a INFORMANT -NAME Fred William Chandler 14b. RELATIONSHIP TO DECEDENT Husband 16. METHOD OF DISPOSITION °Burial °Donation a d Cremation °Entombment 0 esmovat 0 Otheg6pedfy) 160. MB R- SIGNAAT 1 " ' � - ^ n, /► \ tA.A ti•G [ �J! aV 16b. LICENSE NO. / V! 7 16c. DATE (Mo., Day, Yr.) October 14, 2008 16d. C ETERY, CREMATORY OR OTHER LOCATION CITYITOWN STATE Central Nebraska Cremation Service Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 To Be Completed by: CERTIFIER CAUSE OF DEATH (See instructions and examples) 1e. PART I. Enter the chain cravats - diseases. InJudee. or complications -that directly cawed the death. DO NOT enter tennInel events such es cardise wrest, I APPROXIMATE INTERVAL respiratory wrest or ventricular abdllation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add addalonel lines if necessary. IMMEDIATE CAUSE: I onset to death IMMEDIATE CAUSE (Final � ^ t I �i disease or condition resulting a) f j/' IOC- a v la , '`-') .. � .,( r A In death) I DUE TO, OR AS A CONSEQUENCE OR 1 onset to death Sequentially Ilst conditions, If b) I any, leading to the cause listed on line a DUE TO, OR AS A CONSEQUENCE OF: i onset to de ath I Enter the UNDERLYING CAUSE 6 ) I (disease or Injury that Initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LAST I 4) 1 18. PART 1L OTHER SIGNIFICANT CONDITIONS - Conditions co ntributing to the death but not resulting In the underlying cause given M PART 1. CII4 19 WAS MEDICAL EXAMINER , OR , CCORONER CONTACTED? YES ❑ NCI 20. IF FEMALE: Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑Unknown if pregnant within the past year 21 MANNER OF DEATH Naturel ❑Homicide ❑ Accident ❑ Pending Investigation 0 Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES `+ O 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES .g NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At hone, farm, street, factory, office bullding, construction alts, etc. (Specify 22d. INJURY AT WORK? ° YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITYITOWN STATE ZIP CODE as i N i ;i u e - .0 e t 23a. DATE OF DEATH (Mo., Day, Yr.) October 11, 2008 kg 1 7 N . 2 ,. ENaa 8 K Z , g 8O 12 so V O 24e. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH m 23b. DATE SIGNED (Mo., Day, Yr.) ( / /(to 23c. TIME OF DEATH 11:05 a.m. 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD • m 23d. To the bast of k • wiedge, death occurred at the ti me, date and place and due ' e - s) stated. (Signature and 1111e) / 24e. On the basis of examination and/or Investigation, In my opinion death occurred at the time, date and place and due to the comets) stated. (Signature and Title) 25. DID TOBACCO US - CONTRIBUTE • THE DEATH? ° YES %NO ❑ PROBABLY ❑ UNKNOWN no HAS ORGAN OR TISSUE j1,ONATION BEEN CONSIDERED? ❑ YES 12F.NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES I® NO 27. NAME. TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) TravisHageman M.D., 729 N. Custer Ave., Grand Island, NE 68801 a 28a. REGISTRAR'S SIGNATURE 4 4 4. A. 28b. D ATE FILED BY REGISTRAR (Mo., Day, Yr.) OCT 2 0 2008 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANL LJMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPA/,ZN.)EtVT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.. DATE OF ISSUANCE DEC 16 2015 LINCOLN, NEBRASKA 201702964 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN v li(7� STRNLEY S. COOPER ASSISTANT STATE REGISTRAR E VARTNlE0' 4E IIC ILTH AN /HtMAN SERVICE$ 3 548