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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 11/22/2016 LINCOLN, NEBRASKA 201707530 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Dorothy Lorrine Pesha 7. SOCIAL SECURITY NUMBER 505 -32 -2227 86. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility i. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Shelton, Nebrask K 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska E 9d. STREET AND NUMBER A , 2739 Lakewood Drive 2 5a. AGE Last Birthday (Yrs.) 84 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9e. APT. NO. 10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Thomas J ! Pesha 11. FATHER'S -NAME (First, Middle, Last, Suffix) Elden E Hodges 9 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Dorothy Smith a 2. 15. METHOD OF olsPOSITItNJ E Burial ❑ Donation 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or 1)nk.) NO 16a. EMBALMER - SIGNATURE Tracey Dietz DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Coronary Artery Disease (disease or tnjurythet 4'44t0 ; Ring in death) 20. IF FEMALE ❑ Not pregnam within past year ❑ Pregnant at time of death ❑ Not pre but pregnant within 42 days of death ❑ Nat pregnant, but pregnant 43 days to 1 year before death ❑ Unknown it pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 14a. INFORMANT -NAME Thomas J Pesha 5b. UNDER 1 YEAR MOS. DAYS 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) November 12, 2016 6. DATE OF BIRTH (Mo., Da February 22, 1932 Yr.) 8d. COUNTY OF DEATH Hall ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Grand Island City Cemetery Grand Island STATE Nebraska 16b. LICENSE NO. 1328 9f. ZIP CODE 68801 9g. INSIDE CITY Limas ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) November 17, 2016 7a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home. 1123 W. 2nd, Grand Island. Nebraska 17b.2ap'Code 68801 CAUSE OF DEATH (See instructions, and examples) 18. PART I. Enter the chain or events -- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional tines it necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Multi system Organ Failure disease or condition resulting APPROXIMATE INTERVAL. onset to death Days !rl deat ) Sepuentlallysist conditions, ff any, feeding to the cause Gsted on line a DUE TO, OR AS A CONSEQUENCE OF: b)Congestive Heart Failure onset to death Years onset to death 11 Months the events rasa - LAST DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not resulting in the underlying cause given In PART I. Venous Insufficiency With Ulceration, Chronic Renal Insufficiency, Diabetes, Interstitial Lung Disease, Rheumatoid Arthritis, Hypothyroid, Paroxysmal: Atrial Fibrillation, Lumbar Spine Stenosis 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY 0 Dttver/Operator ❑ Passenger 0 Pedestrian 0 Other (Specify) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES' E NO 21c. WAS AN AUTOPSY PERFORMED? - ❑ YES E NO 21d. WERE AUTOPSY ENDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 2d. INJURY AT WORK? OYES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 23a. DATE OF DEATH (Mo., Day, Yr.) November i12, 2016 23b. DATE SIGNED (Mo., Day, Yr.) November 16, 2016 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) Kimberly A. Mickels, MD 25. DM TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES E NO ❑ PROBABLY ❑ UNKNOWN 23c. TIME OF DEATH 12:48 PM CITY/TOWN 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr. STATE ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 24e. On the basis o1 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) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? ❑ YES ® NO Not Applicable if 26a is NO ❑ 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 I $ SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, ;Yr. November 17, 2016