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STATE OF NEBRASKA DATE OF ISSUANCE WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND N SERVICES, IT CERTIFIES THE BELOW TO EE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA WO DW AL.TH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAI+S 31 : . 20180317i A A T ST + 4 DEPART'MENT--.0F; LINCOLN, NEBRASKA HUMAN- SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES,' a ' 11/06/2013 CERTIFICATE OF DEATH 1O 01756 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Joyce Ellen Stoner 2. SEX '. Female • 3 i D/%T,E, OF DEATH (M1 :; Day, Yr.) , June 22', 20.1tr 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Culbertson, Nebraska 5a. AGE - Last Birthday (Yrs.) 76 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE 003IRTH (Mo., Day, Yr.) September 1, 1933 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -36 -1626 8b. FACILITY -NAME (If not Institution, give street and number) Tiffany Square Care Center 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) Sc. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 Sd. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1207 W. Division Street e. APT. NO. r 9f. ZIP CODE I 68801 9g. INSIDE CITY LIMITS ® 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 Clarence Stoner 11. FATHER'S -NAME (First, Middle, Last, Suffix) Fred Frick 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ruth Sinner 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or unk.) No 14a. INFORMANT -NAME Clarence Stoner 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Tracey Dietz 16b. LICENSE NO. 1328 16c. DATE (Mo., Day, Yr.) June 26, 2010 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Memorial Park 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 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the Chain of events - diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events r s such as cardiac arrest, 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) Metastatic Bladder Cancer disease or condition resulting onset to death 14 Months in death) DUE TO, OR AS A CONSEQUENCE OF: : 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: ' onset to death Enter the UNDERLYING CAUSE C) I (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 18. 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? o YES ® NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death 0 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 21e. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation Suicide Could not be determined 0 ❑ 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? DYES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE „W i z r is 23s. DATE OF DEATH (Mo., Day, Yr.) June 22,2010 r > e a v E r ° a a z " W i O 8 2 p o D D (9- o s 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) June 23, 2010 23c. TIME OF DEATH' I 11:30 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD i, 0 3d. To the best of my knowledge, death occurred at the time, date and place 2 D and due to the cause(s) stated. (Signature and Title) o a g Jana VanWie, MD 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) 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 Jana VanWie, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803 1 28a. REGISTRAR'S SIGNATURE I 28b. DATE FILED BY REGISTRAR (MO., Day, Yr.) June 25, 2010 STATE OF NEBRASKA DATE OF ISSUANCE WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND N SERVICES, IT CERTIFIES THE BELOW TO EE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA WO DW AL.TH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAI+S 31 : . 20180317i A A T ST + 4 DEPART'MENT--.0F; LINCOLN, NEBRASKA HUMAN- SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES,' a ' 11/06/2013 CERTIFICATE OF DEATH 1O 01756