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To be completed/verified by: FUNERAL DIRECTOR 1 1 . DECEDENTS -NAME (First, Middle, Last, Suffix) e Coleen Rae Fagan ?. ek,X ' •' /31 A 4F . ". = ,tapta Q bE$1'H (Mo., Day, Yr.) • • 14 i , 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 63 5b. UNDER 1 YEAR 5c. 11NpER i. Ay ' 0. DAT •OF BIRTH (Mo:, Day, Yr.) v September 10, 1951 MOS. DAYS . HOURS "'&00I$,"I,`t."' 7. SOCIAL SECURITY NUMBER 506 -68 -1924 8b. FACILITY -NAME (If not Institution, give street and number) 2931 Independence Ave 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Home ❑ DOA ❑ Other(Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 Bd. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2931 Independence Ave 9e, APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO tea. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First. Middle, Last, Suffix) If wife, give maiden name Jim Fagan 11. FATHER'S -NAME (First, Middle, Last, Suffix) Robert Clausen 12. MOTHER'S -NAME (First, Middle, Maiden Sumame) Erma Buchfinck 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Jim Fagan 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Gwen K. Hyronemus 16b. LICENSE NO. 1448 16c. DATE (Mo., Day, Yr.) May 27, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston - Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 17b. Zip Code 68803 L To be completed by: CERTIFIER 1 CAUSE OF DEATH (See instructions and examples) 18. PART 1. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, r APPROXIMATE INTERVAL 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) Colon Cancer Metastatic disease or condition resulting onset to death 4 Years in death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death Sequentially list conditions, if b) I any, leading to the cause listed I I on line a. DUE TO, OR AS A CONSEQUENCE OF: i onset to death Enter the UNDERLYING CAUSE c) 1 (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death LAST d) I 1 I. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 1. IF FEMALE: ® Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 49 days to 1 year before death ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ®NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE • ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) May 21,2015 a a''Ya .a 1 Y n aa� Iin�6 u w a 2 ~ cr s - 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) June9,2015 23c. TIME OF DEATH 08:19 AM 24c. PRONOUNCED DEAD (Mo., Day Yr.) 24d. TIME PRONOUNCED DEAD 23d. To INC best of my knowledge, death occurred at INC time, date and place and due to the cause(s) stated. (Signature and Title) Ramaekers, MD 2 4 e, On the basis of examination and/or inveatig lion, In my opinion death occurred al 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? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES El NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ryan Ramaekers, MD, 2116 W. Faidley Avenue, Grand Island, Nebraska 8803 128a. REGISTRAR'S SIGNATURE AO- avow"- 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) June 9, 2015 STATE OF NEBRASKA • WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE 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 VITALRECKVq. 1 DATE OF ISSUANCE 06/12/2015 LINCOLN, NEB 201801540 RASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND H CERTIFICATE OF DEATH , t SDANL Y t6 • •. a { r ASSITA SNT STATE EG,IISJFR BEPAPT ENT OF HEALTH A �J r� HUMAI UM{�N SERVICES ,. 15 03327 ,4