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Ageatta ,, f ^.ue.., :. 3.a\ k 4 } g a. - .._' / k* 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 2 1 0 8 0 0 0 3 0 STANLEY S. OOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 12/18/2017 LINCOLN, NEBRASKA 0. E O u 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Patricia Ann Widga 4, CITY:AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Greeley, Nebraska 7. SOCIAL SECURITY NUMBER 506 -72 -9427 8b. FACILITY -NAME (If not Institution, give street and number) 2011 North Lafayette Avenue 5a. AGE Last Birthday (Yrs.) 63 6b UNDER 1 YEAR MOS. DAYS 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8a: RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9d. STREET AND NUMBER 2011 North Lafayette Avenue Ida, MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) April 26, 2016 August 3, 1952 6. DATE OF BIRTH (Mo., Day, Yr,) 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ® Decedent's Home ❑ Other (Specify) Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ' ® YES ❑ NO lob. NAME OF SPOUSE (First, ; Middle, Last, Suffix) If wife, give maiden name Robert Widga 11. FATHER'S -NAME (First, Middle, Last, Suffix) ' 12. MOTHER'S-NAME (First, Middle, Maiden Surname) Howard Jacobsen Rita Smith 13. EVERIN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk,) NO 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Not Embalmed 16d, CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN Central Nebraska Cremation Services Gibbon STATE Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) ADfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska CAUSE OF DEATH (See instructions and examples) 1S. PART!. Enter the 'chain of evens -- 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. DO NOT ABBREVIATE. Enter only one cause on a line, Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Metastatic AdenoCarcinoma Of The Colon disease or condition resulting in death) Segiteptially list conditions, 8 any, isadtrrg to the cause listed on line a : . DUE TO, OR AS A CONSEQUENCE OF: b) APPROXIMATE !INTERVAL onset to death Years Enter the UNDERLYING CAUSE (disease or injury chat initiated DUE TO, OR AS A CONSEQUENCE OF: c) onset to death the events rasuhil{,m death) _.. 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 I. Pulmonary Embolus, Gastroesophageal Reflux Disease Prediabetes, Urinary Tract infection 20. IF . FEMALE: ® Not pregnant within past year ❑ Pregnant at time of death © Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregsent43 days to 1 year before death ❑ Unknown if pregnantwithirithe past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. NJURY AT WORK? El YES E NO 22b. TIME OF INJURY 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 23 b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH April 26, 2016 01:30 PM g Y 0 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) o I- w . DATE OF DEATH '(Mo., Day, Yr.) April 26, 2016 g " Jav C. Anderson, MD [ 28a, REGISTRAR'S SI NATGRE 14a. INFORMANT -NAME Robert Widga 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 16h LICENSE NO. 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger Pedestrian 0 Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) April 27, 2016 17b. Zip Code 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El 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 24b. TIME OF DEATH 24d. TIME PRONOUNC 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 ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28b. DATE FILED BY REGISTRAR (MO„ Day, Yr.) May 2, 2016 i STATE OF NEBRASKA - DEPARTMENT OF HEALTH! AND HUMAN SERVICES CERTIFICATE OF DEATH