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STATE OF NEBRASKA % , h r b e ro .. - I- v 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Gladys Laurene Mullanix A CITY. AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Culbertson, Nebraska 7. SOCIAL SECURITY NUMBER 507 -38 -1546 $b. FACILITY-NAME (If not Ir'.stitution, give street and number) CHI Health St, Francis 5a, AGE • Last Birthday (Yrs.) 83 UNDER 1 YEAR MOS. 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA 2. SEX Female 5c. UNDER 1 DAY DAYS HOURS MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 3. DATE OF DEATH (Mo., Day, Yr.) November 16, 2016 6. DATE OF BIRTH (Mo. May 26, 1933 Day, Yr) Hospice Facility W d d 0. la 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 12/7/2016 LINCOLN, NEBRASKA 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 d 9a. RESIDENCE -STATE re ` Nebraska 9d. STREET AND NUMBER >, 2415 N. Grand Island Ave. 16a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (drat, Middle, Last, Suffix) Robert Rogers .:EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes,. No, or link.) No 5. METHOD OF DISPOSITION ® Burial 0 Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Met (Specify) 7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska in death) DUE TO, OR AS A CONSEQUENCE OF: 9 equentiallyiiat coOddions, if ! : < b)i mmunocompromised State any, li`ading tb the Cause hated on line a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Multiple Myeloma ( seasearinjury tttatinitlated The events resultinigin death) tAST O. IF FEMALE: 0 Not pregnant within past ye ❑ Pregnant at time of death r 1 x n< rre,.ant .i.t<. a ._.0 .. ❑ Nd pregnant, Out pregnant; 43 days to 1 year before death Unknown iftttegnald within the past year 22a. DATE OF INJURY (Mo., Day, Yr,) 22d...INJURY AT: WORK? YES ❑ NO 23e. DATE OF DEATH (Mo., Day, Yr.) November 6, 2016 DATE SIGNED (Mo., Day, Yr.) November29 2016 a. REGISTRAR'S SI 5. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ta NO ❑ PROBABLY ❑ UNKNOWN ❑ YES El NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 22e. DESCRIBE HOW INJURY OCCURRED d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Kira rlyA. Mickels, MD NA T' p. STATE OF NEBRASKA - DEPARTMENT OF HEALTH! AND HUMAN SERVICES CERTIFICATE OF DEATH 9b. COUNTY I Hall 16a. EMBALMER - SIGNATURE Katie M. Smvdra 16d. CEMETERY, CREMATORY OR OTHER LOCATION Memorial Park Cemetery DUE TO, OR AS A CONSEQUENCE OF: d 22b. TIME OF INJURY 23c. TIME OF DEATH 11:23 AM 201704598 19;c. CITY OR TOWN I ` Grand Island 90. APT. NO. STANLEY S. 'COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES I Hall 9f, ZIP CODE 68803 tub. NAME OF SPOUSE (First, , Middle, Last, Suffix) If wife, give maiden name Gerald Wesley Mullanix 14a. INFORMANT - NAME Gerald Wesley Mullanix 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be detem;ined 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Minnie Milady 16b. LICENSE NO. 1454 CAUSE OF DEATH (See instructions and examples) 1a PART I. Enter tne' Chain of events - -diseases, injuries, or complications -that directly caused death. 00 NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. iMf1:EDIATE CAUSE: IMMEDIATE CAUSE (Final ig)Strep Pneumonia Sepsis disease or condition resultina CITY / TOWN McCook 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART Hypertension:, Acute Renal Failure, Vitamin D Deficiency, Lumbar Spinal Stenosis 21b. IF TRANSPORTATION INJURY Driver /Operator ❑ Passenger Pea 0 Other (Specify) 9g. INSIDE CITY LIMITS EI YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Husband 16c. DATE (Mo., Day Yr.) !. November 22, 2016 STATE Nebraska 17b.Zip;'Code s. 68801 APPROXIMATE onset to death Hours onset to death Years onset to death Years onset to +Jeafh 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES X❑j No 21c. WAS AN AUTOPSY PERFORMED? ❑YES IS] NQ 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(s) stated. (Signature and Title) 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY /TOWN STATE 24a. DATE tiltiNtU (MO., bay', L4 ,. C CF 05 ,.;, irgcnt i0 r ;t r + NGS A4'AiLAS TO COMPLETE CAUSE OF DEATH? . ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES © 28b. DATE FILED BY REGISTRAR ( Mo,, Day, Yr.) L November 29, 2016 CD w ' CO (D 0