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I ll i vv: , talawar 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 8/18/2017 LINCOLN, NEBRASKA 201707744 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Antoinette Mary Blackford 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 505 -44 -2873 b. FACILITY -NAME (If not institution, give street and number) Prairie Winds w w z a 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married t ❑ Married, but separated; ❑ Widowed ® Divorced ❑ Unknown 'O '' 11. FATHER'S -NAME (First, Middle, Last, Suffix) II Harold Isaac Roach 9d. STREET AND NUMBER 315 North Church Street 8c. CITY OR TOWN OF DEATH (Include Zip Code) Doniphan 68832.. 9a. RESIDENCE - STATE Nebraska 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. w (Yes, No, or Unk.) No Z 15. METHOD OF DISPOSITION E ❑ Burial ❑ Donation Not Embalmed Cremation ❑ Entombment ❑ Removal ❑ Others (Specify) 16a. EMBALMER- SIGNATURE 5a. AGE - Last Birthday (Yrs.) 80 14a. INFORMANT -NAME Roger Martin Blackford 5b. UNDER 1 YEAR MOS. DAYS 9e. APT. NO. 16b, LICENSE NO. 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home 0 DOA 0 Other (Specify)ASSISTED LIVING 8d. COUNTY OF DEATH Hall 9b. COUNTY 9c. CITY OR TOWN Hall Doniphan 9f. ZIP CODE 68832 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Johanna Antoinette Warnke CITY / TOWN 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services Gibbon STATE Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska 3. DATE OF DEATH (Mo., Day, Yr.) August 13, 2017 6. DATE OF BIRTH (Mo. August 15, 1936 Day, Yr.). 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Son 16c. DATE (Mo., Day, Yr.) August 15, 2017 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 14. PART 1. Enter the chain of events diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratoty arrest; or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause :aria line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) End -stage Renal Disease, On Hemodialysis disease or condition resulting in death) Sequentially fist conditions, if any,aeadinglo the cause fisted on line a DUE TO, OR AS A CONSEQUENCE OF: b) History Of Severe Peripheral Vascular Disease, ;Hypertension, Coronary Artery Disease, Heart Failure onset to death Years onset to death DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE C) (disease "MPH)/ ihht inCiated the events resul titigin death) IAST ... 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY ATWORK? ❑Y'S ❑NO DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART 11, OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. 20. IF FEMALE: ❑ Not pregnant'withm paiityear ❑ Pregnant at time of death Not Pregnant, but pregnant within. 42 days of death r of pregllam;:tru1 pregnant 43 days to 1 year before death a tMknOV411 if pregnan wlthtn the past year 22b. TIME OF INJURY 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 5. D(D TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED CITY/TOWN 23b. DATE SIGNED (Mo., Day, Yr,) Au•ust14 2017 23c. TIME OF DEATH 08:40 PM 23a. DATE OFDEATH (Mo., Dav, Yr.) August 13, 2017 3d. To the best of my knowledge, death occurred at the time, date and place and due to the causes) stated. (Signature and Title) Jane A. McDonald, MD 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 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) 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803 28a. REGISTRAR'S GNATURE /f ` jd 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) STATE 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES Q NO 28b. DATE FILED BY REGISTRAR August 15, 2017 onset to death:_ 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDIN AVAILABLE TO COMPLETE CAUSE OF DEATH ? ::. ❑ YES ❑ No ZIP CODE 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 0 Day, Yr.) awl STANLEY S. tSOOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES APPROXIMATE INTERVAL Months