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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 7/20/2017 LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Anna Marie Wuehler 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Bad Axe, Michigan 7. SOCIAL SECURITY NUMBER 379,62 -7697 5a. AGE Last Birthday (Yrs.) 64 5b. UNDER 1 YEAR MOS. 8a. PLACE OF DEATH HOSPITAL Q Inpatient DAYS 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. OTHER ❑ Nursing February 23, 1953 3. DATE OF DEATH (Mo., Day, Yr.) July 7, 2017 6. DATE OF BIRTH 1Mo. Day, Yr.) Bb. FACILITY -NAME Of not Institution, give street and number) tY 1 4 15 E . 2rd Street 4 Q u 43.: EVER IN U.S ARMED FORCES? (Yes, No, or Unk.) No Give dates of service if Yes. ce 8c. CITY OR TOWN OF DEATH (Include Zip Code) ° Grand island 68801 94. RESIDENCE STATE Nebraska LL 9d. STREET AND NUMBER ,, 415 E. 2nd Street 10a. MARITAL STATUS AT TIME OF DEATH ®Married 0 Never Married / ❑ Married, but separated;. ❑ Widowed ❑ Divorced ❑ Unknown ,0 11. FATHER'S -NAME (First, Middle, Last, Suffix) 1/ Robert R Hogan 1 12. MOTHER'S -NAME (First, Middle, Doris Stubbs Malden Surname) 1 5. METHOD OF DISPOSITION 102 ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal ❑ Other(Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Curran Funeral Chanel, 3005 S. Locust St., Grand Island, Nebraska PART I. Enter tha chain of everts diseases, injuries, or complications -that directly caused the death. DO NOT entertenninal events such as cardiac arrest, respiratory arrest, or ventr+ru!ar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Acute Myocardial Infarction disease or condition resulting the events uST m:de °_t3r( Sequentially Hat conditiona, any, leading to the Cause listed: 9b. COUNTY Hall 16a. EMBALMER-SIGNATURE Not Embalmed 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY i TOWN Gibbon STATE Nebraska DUE TO, OR AS A CONSEQUENCE OF: b) Chronic Obstructive Pulmonary Disease DUE TO, OR AS A CONSEQUENCE OF: c)Chronic Bronchitis onset to death Years on line a. Enter the ; UNDERLYING CAUSE 0i$44$. et itwjuryiliat inh(ated multi g to death) DUE TO, OR AS A CONSEQUENCE OF: d)Asthma 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given In PART I. Smoking/Tobacco Use {At Least One Pack Of Cigarettes Per Day) C 2O. IF FEMALE: ❑ Not pregnant within past year EL W 0 Pregnant at time of death U • ❑ Not pregnant. but pregnant within 42 days of death 1 Q Not pregnant, but pregnant 43 days to 1 year before death V liil Unknown if pregnant within the past year E 22a. DATE OF INJURY (Mo., Day, Yr.) E O v .. A t= 22d. INJURY AT WOR © YES ❑NO 234, DATE OF D 1 TN (Mo., Day, Yr.) 22b. TIME OF INJURY CAUSE OF DEATH ee i ruc i e ns - nd exam •les 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island' 9e. APT. NO. 21b. IF TRANSPORTATION INJURY Driver /Operator 0 Passenger Pedestrian Q Other (Specify) 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 1Ob. NAME OF SPOUSE (First, John Wuehler Middle, Last, Suffix) If wife, give maiden name 14a. INFORMANT -NAME John Wuehler 160. LICENSE 140. 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) July 8, 2017 17b, Zip; Code 68801 APPROXIMATE INTERVAL onset to death Minutes onset to dea Years onset to death Years 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? El YES 0 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 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 7 23b. DATE SIGNED (Mo., Day, Yr.) p S W _, b ° Z q O 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? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 12 YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES II NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ashley A. Dorwart, Deputy Hall County Attorney, 231 South Locust Street, Grand island, Nebraska, 68802 28b. DATE FILED BY REGISTRAR Mo., Day, Yr.) July 20, 2017 28a. REGISTRA SIGNA'IU.RE 23c. TIME OF DEATH 201800422 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH ❑ ER/Outpatient 11 Dr ;P STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 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) Ashley A, Dorwart, Deputy Hall County Attorney Home /LTC ❑ Hospice Facility Decedent's Home ❑ Other !Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH July 19 2017 Approx. 04;00 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUh,t:t0 D AU July 8, 2017 1 06.40 AM 26b. WAS CONSENT GRANTED Not Applicable if 26a is NO ❑ YES ❑ NO