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xY } +!wan, 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 12/15/2017 LINCOLN, NEBRASKA d tu:: W v 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Rebecca Suzanne Quandt 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Knoxville, Tennessee 7. SOCIAL SECURITY NUMBER 415 -76.. -4439 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand, Island 68803 9a. RESIDENCESTATE Nebraska 9d. STREET AND NUMBER 3176 E. Prairie Rd. 18a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME #First, Middle, Last, Suffix) Charles Henry King 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Margaret King 13 EVER I:N U.S,::ARMED Give dates of service if Yes. (Yes, No, or UnIL) No 15. METHOD OF DISPOSITION 2 L.1 Burial 0 Donation ® Cremation ❑ Entombment ❑ : ❑ 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 Enter the UNDERLYING CAUSE (disease or injury that intialad the events resulting f death) 20. IF FEMALE; IZ Not pregnant within past year 0 Pregnant at time of death ❑ Not ptegnam; tlut pregnant within 42 days of death ❑ Not pregnant,.but pfeanante3 days to 1 year before death Ey,UnknOviti if prllgnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY ATWORK? DYES ❑NO 234. DA. TE OF DEATH (Mo., Day, Yr.) ni }cemb . 2017 23b. DATE SIGNED (Mo., Day, Yr.) December 11, 2017 9b. COUNTY Hall 22b. TIME OF INJURY 23c. TIME OF DEATH 05:25 AM 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 5a. AGE - Last Birthday (Yrs.) 71 5b. UNDER 1 YEAR mos. DAYS 9e. APT. NO. 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH HOSPITAL Inpatient OTHER ❑ Nursing Home /LTC ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 9c. CITY OR TOWN Grand Island 9f. ZIP CODE 68801 1Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden na Arthur Quandt 14a. INFORMANT-NAME Quandt 16a. EMBALMER-SIGNATURE Not Embalmed 16b. LICENSE NO. 3. DATE OF DEATH (Mo., Day, Yr.) December 9, 2017 6. DATE OF BIRTH (Mo., Day, YT,) January 18, 1946 8d. COUNTY OF DEATH Hall 9g. INSIDE CM LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT; Spouse • 16c. DATE (Mo., Day, Yr.) December 12, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Gibbon Central Nebraska Cremation Services STATE Nebraska 1 7b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 1S. PART 1. Etter the Chain of events- -diseases, injuries, or complications -that directly caused the. death. DO NOT enter terminal events such as cardiac arrest, respiratory arreft, or ventnCular 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 Respiratory Failure disease or condition resulting to death) APPROXIMATE INTERVAL onset to death Immediate Sequential(y fiat conditions, if .: '.. • any, feeding to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: b)Chronic Obstructive Pulmonary Disease outlet t/a deattt Years DUE TO, OR AS A CONSEQUENCE OF: c) Chronic Systolic Heart Failure onset to death Months LAST DUE TO, OR AS A CONSEQUENCE OF: d) Recurrent Transudates Pleural Effusion s onset todeath Weeks 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger 0 Pedestrian Other 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 10 NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE. TO COMPLETE CAUSE OF DEATH? 0 YES 0 N 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 p 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Michael A. Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803, ha. REGISTRAR'S SIGNATURE / �- 24a. DATE. SIGNED (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES El NO 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 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) Michael A, Donner, MD lee. 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 28b. DATE FILED BY REGISTRAR (Mo.,;Day, Yr.) December 13, 2017 201801426 STATE OF NEBRASKA - DEPARTMENT OF HEALTH' AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES