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1, u STATE OF NEBRASKA /4 .,, 4,.. 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 201708304 6/16/2017 LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Veronica Theresa Miller 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a, AGE' Last Birthday 8b. FACILITY.NAME (If not Institution, give street and number) O CHI Health St, Francis Lf 8c. CITY OR TOWN OF DEATH (Include Zip Code) o Grand Island 68803 9a. RESIDENCE-STATE Nebraska W U a E 0 u Grand Island!. Nebraska 7. SOCIAL SECURITY NUMBER 508 -56 -0198. 9d. STREET AND N UMBER 1024 Nebraska Ave Wa. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married Married, but separated" . ❑ Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or link.) NO 15. METHOD OF DISPOSITION ❑ Burial CI Donation ® Cremation ❑ Entombment ❑ Removal 0 Other(Specify) (Yrs.) 70 9b. COUNTY Hall Sc, CITY OR TOWN Grand Island MOs, 16a. EMBALMER - SIGNATURE Katie M. Smydra 5b. UNDER 1 YEAR 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA 9e. APT. NO. 2. SEX Female 5c. UNDER 1 DAY DAYS HOURS MINS. OTHER ❑ Nursing Home/LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 14a. INFORMANT -NAME Ronald Raymond Miller 16b. LICENSE NO. 1454 October 15, 1946 9f. ZIP CODE 68801 lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Ronald Raymond Miller 11. FATHER'S -NAME (First, Middle, Last, Suffix) John Powell 12. MOTHER'S -NAME (First, Christina O'Neill Middle, Maiden Surname) 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY I TOWN 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 CAUSE OF DEATH (See instructions and examples) t8. PAM. Enter the chain of events -- diseases, injuries, or complications -that directly caused the 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 lures H necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Metastatic Mesothelioma disease or condition resulting APPROXIMATE: INTERVA onset to death Months in death) Sequentially fist conditions, if any, leading bathe cause fisted on line a DUE TO, OR AS A CONSEQUENCE OF: b) onset to death DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury :: that initiated at the events resulting in d e 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. Multi system Organ Failure 20. IF FEMALE: ® Not pregnant within past year ❑ Pregnant at time of deat ID Not- pregnant , but p wit hin 42 days of death ❑ Net pregnant, out pregnant 43 days tot year before death ❑ Unknown H pregnant within past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? C] YES c) NO W 4 W E O Z a O 2 u ' w 28a. DATE OF DEATH (Mo., Day, Yr.) JUDE 5, 2017 2 3b. DATE SIGNED (Mo., Day, Yr.) June 6, 2017 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) Chad: Vieth, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES Iia NO ❑ PROBABLY ❑ UNKNOWN 22b. TIME OF INJURY 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ['Could not be determined 23c. TIME OF DEATH 03:18 PM 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger 0 Pedestrian 0 Other:(Specify) 3. DATE OF DEATH (Mo., Day, Yr.) June 5, 2017 6. DATE OF BIRTH (MO.,. Day,Yr.) ❑ Hospice Facility 9g. INSIDE CITY Utili TS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Husband 16c. DATE (Mo., Day, Yr.) June 12, 2017 174. Zip code 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑YES NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? ;: : ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES El NO 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 Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRARS SIGNATURE �- �.. a� 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) June 12, 2017 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES CD CD CD