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it " 00Nabitmi, , ` F;d Ada Ta�:.1 " "t.�. iaPi: hl: /.6 A4 sNud. 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 12/18/2017 LINCOLN, NEBRASKA 201800075 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Rhonda Sue Day APPROXtMATEINTERVAL onset to death • 4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Loup City, Nebraska 7. SOCIAL SECURITY NUMBER 505 - 82 -6385 8b. FACILITY -NAME (If riot Institution, give street and number) 0 I 2907 W. State St ce • 8c. CITY OR TOWN OF DEATH (Include Zip Code) 6 __ Grand Island 68803 a. RES1DENCE:S TATS Nebraska 2 . LL ' 9d. STREET AND NUMBER 2907 W. State St .0 O 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, bit separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) David Fredrick E • 13, EVER IN U.S, ARMED FORCES? Give dates of service if Yes. E • (Yes, No, or Unk,) NO 15 METHOD SF DISPOSITION t O ® Burial ❑Donation ❑ Cremation 0 En tombment ❑ Removal El Other(Sp lfy in death) Sequentially list COCddlona, if any, leading to the cause listed on line a DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease ortnjuryd 8t in tMed the events tesultkfg m death) LAST ce W O 20. W FEMALE: ▪ Not pregnant within past year ❑ Pregnant at time of death Not magnate, taut pregnant within 42 days o/ death ❑ Not pnant, Avt miaow 43 days to 1 year before death tlnknreg i t pregnant within the past year e 22a. DATE OF INJURY (Mo., Day, Yr.) O 0 2 22d. INJURY AT WORK? H 13 YES El NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 23a. DATE OF DEATH (Mo., Day, Yr.) 23b. DATE SIGNED (Mo., Day, Yr,) 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Patricia R. Curran 22b. TIME OF INJURY 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 23c. TIME OF DEATH 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) :25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN 5a. AGE - Last Birthday (Yrs.) 61 28a. REGISTRAR'S SIGNATURE /j,f o 513. UNDER 1 YEAR MOS. DAYS 2. SEX Female 5c. UNDER 1 DAY HOURS 9e. APT. NO. MINS. 9f. ZIP CODE 68803 14a. INFORMANT-NAME Dennis Dav 16b. LICENSE NO. 1092 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Curran Funeral Chapel. 3005 S. Locust St.. Grand Island, Nebraska 18. FRAIL Enter the chain of events -- diseases, injuries, or complications that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arras*, of 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 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 24a. DATE SIGNED (Mo., Day, Yr.) December 8, 2017 24c. PRONOUNCED DEAD (Mo., Day, Yr.) December 2, 2017 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES 5a NO 3. DATE OF DEATH (Mo., Day, Yr.) December 2, 2017 May 9, 1956 6. DATE OF BIRTH (Mo., Day, Yr.) 8a. PLACE OF DEATH HOSPITAL 0 Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home/LTC El Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 9g. INSIDE CITY LIMITS` El YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Dennis Day 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ramona Ross 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day,' Yr.) December 7, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Cemetery CITY / TOWN Grand Island STATE Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) DUE TO, OR AS A CONSEQUENCE OF: b) IgLON 5 Disease ( Neurol Neuroimmunol Neuroinflam onset to death Year onset to death DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES Ea NO 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? 0 Driver /Operator E ❑ YES El NO ❑ Passenger 0 Pedestrian D Other (Specify) 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 CITY/TOWN STATE ZIP CODE 24b. TIME OF DEATH • Approx. 07 :00 AM 24d. TIME PRONOUNCED DEAD 09:08 AM 24e. On the basis of examination and/or Investiga ion, In my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Tide) S. Alex West, Hall Deputy County Attorney 26b. WAS CONSENT GRANTED? i Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print S Alex West, Hall Deputy County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801 28b. DATE FILED BY REGISTRAR (Mo.,Day, Yr.) December 14, 2017