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tia& AI 1 � ARda'rr 1. I /�. u, .N1 At.... 1 'N.. ... ,.'1 STATE OF NEBRASKA =CI MextC "sr 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 OF ISSUANCE 11/7/2017 LINCOLN, NEBRASKA 201800004 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND, HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 23b. DATE SIGNED (Mo., Day, Yr.) 0 ober25 2017 23c. TIME OF DEATH 03:20 AM 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Betty Rose Sandoe 4. CITY AND-STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 505 -72 -2781 8b. FACILITY -NAME (If not Institution, give street and number) Wedgewood Care Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island. 68803 9a. RESIDENCESTATE Nebraska 9d. STREET AND NUMBER 515 W 16th Street Oa. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated; ® Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Henry Meinecke 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk I No 15. METHOD OF RISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal © Other(Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island, Nebraska DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) idiseese or injury that initiated, the events resugieg in death) LAST : DUE TO, OR AS A CONSEQUENCE OF: 0. IF FEMALE ® Not pregnant within past y e ar ❑ Pregnant at time of death ❑ Natpregnenf,`hut p regnatet within 42 days of death Q Not pregnant, e t p days year before death ❑ unknown if preg witliip the past year to 1 22a. DATE OF INJURY (Mo., Day, Yr.) d. INJURY AT WORK? ©YES NO d) 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. DATE OF DEATH (Mo., Day, Yr.) October 25€ 2017 9b. COUNTY Halt 16a. EMBALMER - SIGNATURE Not Embalmed 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED To the best 01 my knowledge, death occurred lathe time, date and place and due to the cause(s) stated. (Signature and Title) nnifer L. 8rOwn, MD 5a. AGE - Last Birthday (Yrs.) 68 5b. UNDER 1 YEAR M OS. 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined CITY/TOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES ONO 25. DID TOBACC USEGONTRIBUTE TO THE DEATH? raj ❑ YES NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jennifer 1_ Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE 6 C DAYS 9e. APT. NO. 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA OTHER ® Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility Sc. CITY OR TOWN Grand Island 9f. ZIP CODE 68801 lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Wade Sandoe 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Virginia Manka 14a. INFORMANT-NAME Chad Sandoe 16b. LICENSE NO. CAUSE OF DEATH (See instructions and examples) a, PART!. Enter the ichain of events -- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arr or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list W?lthtiolta, if b) Metastatic Stage 4 Ovarian Cancer an :leadmg to tha cause listed on line a. 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger Pedestrian 0 Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 3. DATE OF DEATH (Mo., Day, Yr.) October 25, 2017 6. DATE OF BIRTH (MO.., Day, Yr, July 20, 1949 8d. COUNTY OF DEATH Hall 9g. INSIDE CITY LIMITS` 2 YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Son 16c. DATE (Mo., Day, Yr.) October 26, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE Nebras 17b. Zip Code 68801 APPROXIMATE INTERVAL::: onset to death < 1 Month onset to •death < 3 Months onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES I NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑YES 0 N 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) STATE ZIP CODE 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 cause(s) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 0 NO 28b. DATE FILED BY REGISTRAR (MO.,Day, Yr.) October 30, 2017