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I " Q CS U U! 28a. REGISTRAR'S SIGNATURE U- .o w w m d o. E 0 cc W U 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 PATE OF7SSUANCE 201 8 0 2 828 2/22/2018 LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Patricia Joan Placke 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Kearney, Nebraska 7. SOCIAL SECURITY NUMBER 507 -92 -6569 8b..FACILITY.NAME (If n c CHI Health St, Francis c. Cr i r OR i vvv OF i tATH (include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE I9b. COUNTY lebraSka Hall 9d. STREET AND NUMBER 2115 Riverside Drive 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Robert F Thompson 13. EVER IN U,S. ARMED FORCES? Give dates of service if Yes. (Yes, No or link.) No 15. METHOD OF DISPOSITION ❑Burial -❑ Donation ® Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Peters Funeral Home. 302 Second Street. PO Box 181, St. Paul. Nebraska a. PARt I, Enter the chain of events -- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory attest, or Ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: a) Cancer Of The Cervix, Metastatic IMMEDIATE CAUSE (Final disease or condition resulting in death) .... DUE TO, CR AS A CONSEQUENCE OF; SequenballY list cdndltions, u b) any, leading to the cause listed' on lines. • Enter the UNDERLYING CAUSE (disease Or injury :that initiated theevents resultuig in death) LAST 22d :INJURY AT WORK? OYES NO 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 20-IF;FEMALE: 's Not pregnant'within pastyear ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant. Wat 43 days to 1 year before death Unknown it pregnant within the past year • 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 23a. DATE OF DEATH (Mo., Day, Yr February 16. 2018 23b, DATE $ZONED (Mo., Day, Yr.) 23c. TIME OF DEATH February 16, 2018 08:02 AM d. To the best of my knowledge, death occurred at the time, date and place and due to the causes) stated. (Signature and Title) Gar: Settle,..MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES NO ❑ PROBABLY ❑ UNKNOWN Institution, give street and number) STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Not Embalmed :1, err„' 5a. AGE - Last Birthday (Yrs.) 57 14a. INFORMANT -NAME Fred L Massing 16a. EMBALMER - SIGNATURE 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 22e. DESCRIBE HOW INJURY OCCURRED b. U 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Fred L Massing I ' 12. MOTHER'S -NAME (First, Shirley C Lawson CAUSE OF DEATH (See instructions and examples) 21a. MANNER OF DEATH ® Natural 0 Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ CL.dxf novae determined CITYITOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Gary Bettie, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 HOER 1 YEAR 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES NO 9e. APT. NO. 16b. LICENSE NO. Gibbon 24a. BATE SIGNED (Mo., Day, Yr.) j STANLEY/. COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 2. SEX Female 5c. UNDER 1 DAY HOURS OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) i 8d. COUNTY OF DEATH Hall CITY / TOWN 9f. ZIP CODE 68801 214. IF TRANSPORTATION INJURY Driver /Operator ❑ Passenger .❑ Pedestrian Other (Specify) Middle, Maiden Surname) 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) STATE MINS. O"_IN ^ED DEAD (Mo., Day, Yr. 24b. TIME OF DEATH 24e. On the basis of examination and /or investiga ion, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 3. DATE OF DEATH (Mo., Day, Yr.) February 16, 2018 6. DATE OF BIRTH (MG., Day, Y.) March 31, 1960 ❑ Hospice Facility 9g- INSIDE CITY LIMITS El YES ❑ NO 14b. RELATIONSHIP: TO DECEDENT.: Spouse 16c. DATE (MO., Day, Yr:) February 16, 2018 onset to death APPROXIMATE INTERVAL onset to death 2 Years STATE Nebraska 17b. Zip Code 68873 onset to death onsetao death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 21c. WAS AN AUTOPSr PERFORMED?- ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE GAUSS OF OEATrI? ❑ YES ❑ NO ZIP CODE 24d. TIME PRONOI,INCED DEAD 26b. WAS CONSENT GRANTED?I Not Applicable if 26a is NO 0 YES ❑ NO 28b. DATE FILED BY REGISTRAR (MO: Day, Yr,) February 20, 2018