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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE 2 0 1 80 3 4 2 0 STANLEY COOPER
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<br />ASSISTA STATE REGISTRAR
<br />5/21/2018 DEPARTMENT HEALTH AND
<br />LINCOLN, NEBRASKA HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />07,4%" 14 14 00 „Paiskil,;', aka*
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<br />1. DECEDENTS-NAME (First, Middle, Last, Suffix)
<br />Constance Dawn Hameloth
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Neligh, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-76-9287
<br />8b. FACILITY-NAME (If not Institution, give street and number)
<br />1415 Stagecoach Road
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />0 Burial 0 Donation
<br />0 Cremation 0 Entombment
<br />0 Removai 0 Other (Specify)
<br />• Sequentially lisitohditions, If
<br />any leading to theSaUse ltsted
<br />on line a,
<br />20. IP FEMALE:
<br />Not pregnant V! i thi ti pain year
<br />0 Pregnant at time of death
<br />0 Not pregnant, butpregnant within 42 days of death
<br />0 Not pregnant, butpreeneat 43 days to 1 year before death
<br />Unknown if pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />udIN.JuRy
<br />DYES .ONO
<br />23a. pirmcp]:op7o (Mo., Day, Yr.)
<br />May 10. 2018
<br />25:DiD TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />DYES 0 NO • 0 PROBABLY 0 UNKNOWN
<br />Sa. AGE Last Birthday
<br />(Yrs.)
<br />64
<br />9b. COUNTY
<br />Hall
<br />9d. STREET AND NUMBER
<br />1415 Stagecoach Road
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />• 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11:FATHER'SNAMEZ(Firei, Middle, Last, Suffix)
<br />Donald Warren Lambert
<br />16a. EMBALMER-SIGNATURE
<br />Laurie D. Sheffield
<br />22b. TIME OF INJURY
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />?.;
<br />§ a Ma 11, 2018 04:23 PM
<br />zi 0 3d. To the best of my knowledge, death occurred at the time, date and place
<br />!-. and due to the cause(s) stated. (Signature and Title)
<br />Jennifer L. Brown, MD
<br />21a. MANNER OF DEATH
<br />El Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />Suicide 0 Could not be determined
<br />MOS.
<br />I28a. REGISTRAR'S SIGNATURE
<br />Cetrisire.-
<br />51). UNDER 1 YEAR
<br />DAYS
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />9e. APT. NO.
<br />CAUSE OF DEATH 1See instructions and examples)
<br />13. 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,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT AlifIREWATE, Enter only one cause-on a line. Add additional lines if necessary.
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES 0 NO
<br />MINS.
<br />211). IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />24a. DATE SIGNED (Mo., Day, Yr./
<br />9 f. ZIP CODE
<br />68801
<br />14a. INFORMANT-NAME
<br />Steven Robert Hameloth
<br />16b. LICENSE NO.
<br />1397
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street, Grand Island, Nebraska
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />May 10, 2018
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />August 23, 1953
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC
<br />0 ER/Outpatient 0 Decedent's Home
<br />O DOA 0 Other (Specify)
<br />0 Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9g. INSIDE CITY LIMITS
<br />YES 0 NO
<br />10b, NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Steven Robert Hameloth
<br />12. MOTHER'S-NAME (First, Middle, Maiden Surname)
<br />Marjorie Mae Lorenzen
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />16c. DATE (MO., Day, Yr.)
<br />May 16, 2018
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />CITY/TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />STATE
<br />I 7b Zip Code
<br />68801
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />in death)
<br />IMMEDIATE CAUSE:
<br />a) Metastatic Uterine Leiomyosarcoma
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />> 1 Year
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />onset1.0..:deatH „
<br />Enter the UNDERLYING CAUSE
<br />Adiseatebr injury that Initiated
<br />the events remitting in daelh)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />onset to death
<br />(ASTI
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset tra:death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />DYES 0 NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />DYES 0 NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />DYES u NO
<br />22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />t
<br />V 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /><
<br />8 °
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO DYES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 88803
<br />28b. DATE FILED BY REGISTRAR (Mo, Day,: Yr.)
<br />May 16, 2018
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