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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 9/29/2017 COLN, NEBRASKA 201707133 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH atop STANLEY S...OPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES W cc W z E 9d. STREET AND NUMBER 3548 Graham Avenue 10 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married a) ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown et > 11. FATHER'S -NAME (First, Middle, Last, Suffix) d Frank Kunze 0. E 0 m A 0 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Marlene Mae Peters I. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 508 -44 -6950 8b. FACILITY -NAME (If not institution, give street and number) Tiffany Square Oare Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE - STATE Nebraska .. 13, EVER IN U.S.. ARMED FORCES? Give dates of service if Yes. (Yed, No or Unit.) NO 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑.Removal :;❑ Other(Specify) IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting n death) egleatially fist coid'itions, if any, leading to the :cause l(sted' on line a. Enter the UNDERLYING CAUSE (QiseaEe or lnjury::tiiat initiated;::. the events rasuttigg m death) tASt: 20. IF FEMALE:.;: 0 Not pregnantwlthin past year 0 Pregnant at time of death ❑ Not pregnant,: but pregnant within 42 days of death a Not pregnant, but pregnene43 Oays tot year berore deat, ❑ tlriknown ifprpgnantwithasthe past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT:WORK.? ❑YES ❑NO 5a. AGE - Last Birthday (Yrs.) 79 9b. COUNTY Hall 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 14a. INFORMANT -NAME Marvin Vern Peters 16a. EMBALMER - SIGNATURE Tracey Dietz 16d. CEMETERY, CREMATORY OR OTHER LOCATION Grand Island City Cemetery 17a. FVNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska 1Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name'. Marvin Vern Peters 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Paula Trampe CAUSE OF DEATH (See instructions and examples) 18. PA/tT I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter teninnal events such as cardiac arrest, respiratory arreet, or ventdcular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line, Add additional lines if necessary. DUE TO, OR AS A CONSEQUENCE OF: b)Severe /Advanced Alzheimer's Dementia DUE TO, OR AS A CONSEQUENCE OF: 0) DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 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) Douglas Herbek, MD 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide 0 Could not be determined 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE Zia. DATE OF A {Mo., Day, Yr.) September 22, 2017 . 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH September 25, 2017 09:03 PM 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES Ea NO 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES El NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Douglas Herbek, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803 3b. UNDER 1 YEAR MOS. ❑ Pedestrian Ott-er (Teevify) DAYS 2. SEX Female 5c. UNDER 1 DAY HOURS CITY / TOWN MINS. 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island I9e. APT. NO. 19f. ZIP CODE 1 68803 LICENSE NO. 1328 Grand Island 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 3. DATE OF DEATH (Mo., Day, Yr.) September 22, 2017 . 6. DATE OF BIRTH ( MO; Day, Yr.) April 4, 1938 OTHER E Nursing Home /LTC ❑ Hospice Facility ❑ Decedent's Home ❑ Other (Specify) 9g. INSIDE CITY LIMITS ( YES ❑ NO 14b. RELATIONSHIP TO DECEDENT: Spouse 16c. DATE (Mo., Day, Yr.) September 26, 2017 STATE Nebraska 1711. Zip Code 68801 APPROXIMATE INTERVAL: onset to death 1 -2 Days onset todeath :: 5 Years onset todeath• 214 IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? ❑ Driver /Operator ❑YES ElNO ❑ Passenger 19. WAS MEDICAL EXAMINER OR CORONER CONTACTEO? ❑YES ®:r10 21d. WERE AUTOPSY FINDINGS AVAILABL: TO COMPLETE CAUSE OP DEATH? ❑YES ❑NO 24b. TIME OF DEATH'. 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 causes) stated. (Signature and Tide) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) September 27, 2017