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STATE OF NEBRASKA •. xsir A. r§ 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 2/7/2017 LINCOLN, NEBRASKA 201708627 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME II Cote STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Mildred Marie Reeder 4 CITY STATE OR TE RRITORY, OR FOREIGN COUNTRY OF BIRTH Wood River, Nebraska 7. SOCIAL SECURITY NUMBER 505 -68 -4105 8b. FACILITY -NAME (If not Institution, give street and number) 6720 Wiseman Road 9a. RESIDENCE STATE Nebraska 10a. MARITAL STATUS AT OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated;. ® Widowed ❑ Divorced ❑ Unknown 5 . AGE - Last Birthday (Yrs.) 93 9b. COUNTY Buffalo 5b, U NDER 1 YEAR MOS. DAYS 8c. CITY OR TOWN OF DEATH (Include Zip Code) Shelton 68876 9d. STREET A ND'NUMB£R 6720 Wiseman Road 9e. APT. NO. 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 9f. ZIP CODE 68876 3. DATE OF DEATH (Mo., Day, Yr.) January 29, 2017 6. DATE OF BIRTH (Mo. December 8, 1923 8a. PLACE OF DEATH HOSPITAL ❑ inpatient ❑. ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ® Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Buffalo 9c. CITY OR TOWN Shelton 9g. INSIDE CITY LIMITS' ❑ YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Ralph Reeder 11. FATHER'S -NAME (First, Middle, Last, Suffix) Phillip Burmood 4 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mildred Cross CAUSE OF DE H ee in true i P ns and exam les 14. PART f. Enter the chain of events - - diseases, injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratoryarre5t, orventriosilar fibrillation without showing the etiology. DO NOT Aa9REVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: a) Myocardial Infarction APPROXIMATE INTERVAL onset to death Minutes 15. METHOD OF:D ® Burial u Donation ❑ Cremation ❑ Entombment ❑ Removal other (Specify) 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, state) Aofel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska IMMEDIATE CAUSE (Final disease or condition resulting le;:death( Settueiltially list contlhions, if any leading to the.Cense Meted on line DUE TO, OR AS A CONSEQUENCE OF: b)Congestive Heart Failure Enter the UNDERLYING CAUSE (tliseaSe or injury that inalated::< DUE TO, OR AS A CONSEQUENCE OF: c) onset to death . the events resulting, fn death) *AST ` ... .... DUE TO, OR AS A CONSEQUENCE OF: d) onset to death: 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Dementia 20. IF;F`EMALE: 0 Not pregnant within Set year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death Not pregnent, pregnant:43 days to 1 year before death ❑ Unknown if pregnant wahiitthe past year 22a, DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT:WORK4 ]YES QNO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. U 3a. DATE QF DEATH (Mo., Day, Yr.) 23b. DATE 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED GNED (Mo., Day, Yr.) 23c. TIME OF DEATH 34. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES NO ❑ PROBABLY ❑ UNKNOWN 16a. EMBALMER-SIGNATURE Christopher J. Loecker 16d. CEMETERY, CREMATORY OR OTHER LOCATION Shelton Cemetery CITY / TOWN Shelton STATE Nebraska 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined CITY /TOWN 28a. REGISTRAR'S SIGNATURE 4j .1Lr/'ti 16b, LICENSE NO. 1421 21b. IF TRANSPORTATION Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) INJURY 24a. DATE SiGNca (leo., ,ay, t r.) ¢ ( February 1,2017 w O 24c. PRONOUNCED DEAD (Mo., Day, Yr.) o January 29, 2017 y W C � o 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES El NO 16c. DATE (Mo., Day, Yr.) February 3, 2017 17b. Zip Code 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 511 NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office budding, construction site, etc. (Specify) STATE "ZIP CODE 24b. Unknown .. 24d. TIME PRONOUNCED DEAD 07:40 AM 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) Patrick! M. Lee, Buffalo Deputy County Attorney 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Patrick M. Lee, Buffalo Deputy County Attorney, 16th & Central Ave, Courthouse P.O.Box 67, Kearney, Nebraska, 68848 28b. DATE FILED BY REGISTRAR (Ms., Day, Yr.) February 1, 2017