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STATE OF NEBRASKA e w 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 02/19/2016 LINCOLN, NEBRASKA 11. DECEDENTS -NAME (First, Middle, Last, Suffix) Wanda May Hutchinson 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Granite City, IllinO'IS' 7. SOCIAL SECURITY NUMBER 495 -76 -1666 8b. FACILITY -NAME (If not Institution, give street and number) Tiffany Square Care Center c, CITY CP. TOWN CF. DEATH (include Mr.. Cede) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 213 Apricot Lane 11. FATHER'S -NAME (First, Middle, Last, Suffix) James Ohl 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No or Unk.) No 15. METHOD OF DISPOSITION ®Burial 0 Donation ❑ Cremation ❑ Entombment Removal ; ❑ Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfe) Funeral Horne, 1123 W. 2nd, Grand Island, Nebraska Enter the UNDERLYING CAUSE fdise se or injury MM rentated the events resulting in death) LAST 20. IF FEMALE: ® Not pregnant within past year ❑ Pregnant at time of death 0 Not pregnant; but preg within 42 days of death Not pregnank but pregnant -43 days to 1 year before death 0 Unknown if pregnant within the past year 22d. INJJURY A17 WORK' a. DATE OF DEATH (Mo., Day, Yr.) February 13, 2016 23 b. PATE SIGNED (Mo. Day, Yr.) February 15, 2016 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Tracey Dietz Wyuka Cemetery DUE TO, OR AS A CONSEQUENCE OF: c)Acquired Cerebellar Degeneration DUE TO, OR AS A CONSEQUENCE OF: d) I 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 23c. TIME OF DEATH 12:17 AM 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Isaac J. Berg, MD 2018022(2 5a. AGE - Last Birthday 613. UNDER 1 YEAR CITY/TOWN {Yrs.) 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 14a. INFORMANT -NAME Michael C Hutchinson 16d. CEMETERY, CREMATORY OR OTHER LOCATION 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Coutt[ not be determined EGISTRAWS SIGNATURE Asertti- ac MOS. DAYS 9c. CITY 012 TOWN Doniphan Se. APT. NO. CAUSE OF DEATH (See instructions and examples) STANLEY S. S OPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES b. LICENSE NO. 1328 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS 0 0 YES 0 NO 0 PROBABLY ❑ UNKNOWN ❑ YES 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803 Lincoln 2. SEX Female 5c. UNDER 1 DAY HOURS 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68832 Oa. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Michael C Hutchinson 12. MOTHER'S -NAME (First, Middle, Wanda Whimberly CITY /TOWN 8. PART L Enter lse chain of events-- diseases, injuries, or complications -that directly caused the death. DO: NOT enter terminet events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter petty one cause on a trite. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or c ^_nd•iticr resstt;ng m death) DUE TO, OR AS A CONSEQUENCE OF: sequentiailyhsieondit(ons,if b)Pneumonia any, Leading to the cause listed on line a. 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger Pedestrian ❑ Other (Specify) OTHER ® Nursing Home /LTC ❑ Hospice Facility ❑ Decedent's Home ❑ Other (Specify) STATE 24a. DATE SIGNED (Mo., Day, Yr.) GAN:OR TISSUE DONATION BEEN CONSIDERED? ® NO MINS. 3. DATE OF DEATH (Mo., Day, Yr.) February 13, 2016 6. DATE OF BIRTH (MO., Day, Yr.) February 10, 1961 Maiden Surname) 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo„ Day, Yr.) February 19, 2016 APPROXIMATE INTERttAI onset to des 2 Days onset `to death 1 Week onset to death 6 Months 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES Et NO 21c. WAS AN AUTOPSY ❑ YES ® NO 24b. TIME OF DEATH 9g. INSIDE CITY LIMITS 0 YES ❑ NO STATE Ne1raSka 1711. Zip Code 68801 PERFORMED ?: 21d. WERE AUTOPSY FINDINGS AVAILABLP TO COMPLETE CAUSE p F DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) ZIP CODE 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD 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) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mo. 0 February 16, 2016 Yr.