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tere STATE OF NEBRASKA veretwavo LINCOLN, 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 201800095 STANLEY S. DOPER ASSISTANT STATE REGISTRAR 11/27/2017 DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH H tJ w 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Sharon Kay Lammers 4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 505 -52 -6846 8b, FACILITY -NAME (0 not Institution, give street and number) CHI Health St. rrancis 5 AGE • Last Birthday (Yrs.) 75 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska z • .0 1. FAT" ER S - iiAikE IFirst, Middle, Last, Suffix) d Lloyd Ca rruth 9b. COUNTY Hall MOS. 9d. STREET AND NUMBER 4324 N Lariat Ln. 1 4a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated s ❑ Widowed ❑ Divorced ❑ Unknown tY w : 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Small Bowel Obstruction, Arteriosclerotic Cardiovascular Disease, Osteoporosis I 13. EVER IN U.S, ARMED FORCES? Give dates of service if Yes. I I (Yes, No or Unk.) NQ ;p 5. METHOD OF DISPOSITION 2 ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) yi 0. IF FEMALE: LL, Not pfegnan, Within pest year U❑ Pregnant at time of dea Rs! otpregn : Su t pragnalltwithin 42 days of death `LS Not pregn but pregnam:61 da to 1 yea before death Er tJnkngam if pregnant w it h in the past year B. DATE OF DEATH (Mo., Day, Yr.) November 4, 2017 23b. DATE SIGNED (Mo., Day, Yr.) November 15, 2017 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 2 YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 14a. INFORMANT -NAME Weert Lammers 16a. EMBALMER- SIGNATURE Matthew T. Myers DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING: CAUSE c) Severe Chronic Obstructive Pulmonary Disease ldisease or intury tnat inn*" s ettingin death) DUE TO, OR AS A CONSEQUENCE OF: d) E 22a. DATE OF INJURY (Mo., Day, Yr.) O : *4 22d. IN,lt)RYATSNORK? 22e. DESCRIBE HOW INJURY OCCURRED 12 ❑YES 0 N 1 22b. TIME OF INJURY y, : g "z 3d. To the best of my knowledge, death occurred at the time, date and place and due to the sause(s) stated. (Signature and Title( ~ a Steven H uSan. MD 21a. MANNER OF DEATH El Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 23c. TIME OF DEATH 10:05 PM 5b, UNDER 1 YEAR 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, 68803 28a. );EGiSTRAR`S S1GNATURE ,� j6- 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) Hospice Facility 9c. CITY OR TOWN Grand Island 10b. NAME OF SPOUSE. (First, .Middle, Last, Suffix) If wife, give maiden name:::. Weert Lammers i2. MOTHER'S -NAME (First, Middle, Maiden Surname) Opal Clement 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Memorial Park Cemetery CITY / TOWN Grand Island STATE Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livingston- Sondermann Funeral Home. 601 N. Webb Road, Grand Island. Nebraska CAUSE OF DEATH (See instructions and examples) it PART I Enter thethain of events - diseases, injuries, or complications -that directly caused the: death. DO NOT enter terminal events such as cardiac arrest, respiratory erreSt, 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) Acute On Chronic Respiratory Failure disease or condition resulting in: death) APPROXIMATEINTERVAL onset to death 3 Days Sequentially l ist COnttmons, any, leadurgto thecauselistell on line a DUE TO, OR AS A CONSEQUENCE OF: b)Pneumonia onset to death 3 Days onset to death >20 Years fhe events LAST 2111 IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger 0 Pedestrian ottter(specify, 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES 2 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 investiga Mn, in my opinion death occurred at the time, date and place and due to the causes) stated. (Signature and Idle) DAYS 5c. UNDER 1 DAY 2. SEX Female HOURS 9e. APT. NO. MINS. 9f. ZIP CODE 68803 April 26, 1942 6. DATE OF BIRTH (Mo., Day, Yr.) 16b. LICENSE NO. 1411 3. DATE OF DEATH (Mo., Day, Yr.) November 4, 2017 8d. COUNTY OF DEATH Hall 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT,. Spouse 16c. DATE (Mo., Day, Yr.) November 7, 2017 17b.ZipCode 68803 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES] NO 21c. WAS AN AUTOPSY PERFORMED? ❑YES RI NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 28b. DATE FILED BY REGISTRAR (Mo., :Day, Yr.) November 17, 2017