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To be completedNerified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Mary Pauline Richardson 2. SEX . Female 3. DATE OF DEATH (Mo., Day, Yr.) January 30, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Ericson, Nebraska 5a. AGE - Last Birthday (Yrs.) 74 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) April 2, 1939 MOs. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506-52 -9535 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center 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 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 212 North Harrison e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS M YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated ® Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Samuel E Richardson 11. FATHER'S -NAME (First, Middle, Last, Suffix) Paul Johnson 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Cecelia Hardy 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Daisy Richardson -Kelly 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Chris McCoy 16b. LICENSE NO. 1191 16c. DATE (Mo., Day, Yr.) February 4, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 r CAUSE OF DEATH (See instructions and examples) I To be completed by: CERTIFIER 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, - APPROXIMATE INTERVAL onset to death 1 Week respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a One. Add additional lines it necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b)Chronic Obstructive Pulmonary Disease any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c ) (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART H. 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 E3 NO 20. 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 43 days to 1 year before death ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide o Accident ❑ Pending Investigation ❑ Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestnan ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 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 W i , 3 u a 23a. DATE OF DEATH (Mo., Day, Yr.) January 30, 2014 E - z t I ,. 1 F, ,.` z °u C O W $ p ` 0 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) January 31, 2014 N 23c. TIME OF DEATH I 09:30 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3d. To the best of my knowledge, death occurred at the time, date and place c and due to the causes) stated. (Signature and Title) m Donald Wirth, MD 24e. On the basis of examination and /or Investigation. In my op 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 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ID NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Donald Wirth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE A 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) February 10, 2014 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ,4 [�;H�/,N1 IA/ SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEB'RASKA'E) c HEALTH AND HUMAN S E R V I C E S , V I T A L RECORDS O F F I C E , WHICH I S T H E LEGAL DEPOSITORY F O R TAf "rPRJ. S .µ1 ash DATE OF ISSUANCE 02/13/2014 LINCOLN, NEBRASKA 201802057 A§ISTA.t(IT¢b A7€ [GISTRAR 'pEPt1RTM£NT OF HEALTH AND HDMAN.SERVICES, r '~ • STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES , 't ' • CERTIFICATE OF DEATH