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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 5/17/2018 LINCOLN, NEBRASKA 201803235 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY`` COOPER ASSISTA n' STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Barbara Joyce Beckman 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Omaha, Nebraska 7. SOCIAL SECURITY NUMBER 506 -52 -0380 8b. FACILITY -NAME (If not Institution, give street and number) 4133 Sandalwood Drive 5a. AGE - Last Birthday (Yrs.) 7S MOS. 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. REStDENCE.STATE Nebraska 9b. COUNTY Hall 9d. STREET AND NUMBER 4133 Sandalwood Drive 10a, MARITAL. STATUS AT TIME OF DEATH ® Married ❑ Never Married d Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk,) No 15. METHOD OF DISPQSJTION 0 Burial ❑ Donation ® Cremation ❑ Entombment ❑; Removal ❑ Other (Specify) Enter the UNDERLYING CAUSE (disease or injury that initiated thaevent sresuttiep m death) LAST • 265F FEMALE 0 Not pregnant within past year ❑ Pregnant at time of death Not pregnant, but pregnant within 42 days of death ❑ Notpregnant but pregnant 43 days to 1 year before death ❑ Unknown it pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d „ INJURY AT WORK? ❑YES ❑NO 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? YES 0 NO ❑ PROBABLY ❑ UNKNOWN 1 28a, R ed)BT RA .'S SIGNATURE /� 14a. INFORMANT -NAME William G' Beckman 16a. EMBALMER- SIGNATURE Not Embalmed 22b. TIME OF INJURY 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH v z May 4, 2018 01:10 PM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) J23a DATE OF DEATH (Mo., Day, Yr.) Ma v.:3., 2018 Jay C. Anderson, MD 5b, UNDER 1 YEAR DAYS 2. SEX Female 5c. UNDER 1 DAY HOURS 9e. APT. NO. MINS. 21h. IF TRANSPORTATION INJURY ❑' Driver/Operator ❑ Passenger 0 Pedestrian 0 Other(Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONAPON BEEN CONSIDERED? ❑ YES RI NO 9f. ZIP CODE 68803 1bb. LICENSE NO. 178, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART!. coronary artery disease, Hypertension, Hyperlipidemia, Osteoarthritis, Lumbar Spine Degenerative Disease 3. DATE OF DEATH (Mo., Day, Yr.) May 3, 2018 6. DATE OF BIRTH (Mo., Day, Yr.) April 22, 1942'' 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ® Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand island 9g. INSIDE CITY LIMITS ® YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden William C > Beckman ame 11. FATHER'S -NAME (First, Middle, Last, Suffix) Milton Sommerfeld 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Pauline Hansen 14b. RELATIONSHIP TO DECEDENT Husband 16c. DATE (Mo., Day, Yr.) May 7, 2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE Nebraska !; 17h, z 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. Dell NOT enter terminal events such as cardiac arrest, respiratory arrest, or vemtikular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines a necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Breast Cancer - recurrent With Brain Metastasis disease or condition resulting in death) APPRQXIMATEINTERVAL onset to death Months Sett' entidlly list renditions, if any leading to the €cause bitted on line a DUE TO, OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: c) onset to death DUE TO, OR AS A CONSEQUENCE OF: d) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES. ®NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 0 N 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES 0 NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY- STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 24e. On the basis or examination and/or investiga ion, in my opinion death occurred at the time, dare and place and due to the cause(s) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803, 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) May 11, 2018