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1I YXY f 0 XX? WSKRZMW I STATE OF NEBRASKA 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 4/23/2018 LINCOLN, NEBRASKA 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Eleanore D Fuller 4. CITY•AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Doniptlan, Nebraska 7. SOCIAL SECURITY NUMBER 507-24-5311 8b. FACILITY -NAME (If not Institution, give street and number) Veterans Affairs Medical Center ga. RESIDENCE -STATE Nebraska 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married 0 Married, but separated ® Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 07/22/1944- 07/13/1946 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ;© Other (Specify) 50. AGE - Last Birthday #Yrs.) 91 MOS. 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9b. COUNTY Hall 1 9c. CITY OR TOWN Aida 9d. STREET AND•NUMBER 2280 S. Engleman Road 11. FATHER'S -NAME (First, Middle, Last, Suffix) Walter Bruenecke 14a. INFORMANT -NAME Steven L Fuller 16a. EMBALMER - SIGNATURE Gwen K. Hyronemus 5b. UNDER 1 YEAR DAYS 2. SEX Female 5c. UNDER 1 DAY HOURS 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/Outpatient 0 boa OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) Hospice Facility MINS. 8d. COUNTY OF DEATH Hall 9e. APT. NO. 9f. ZIP CODE 68810 10b. NAME OF SPOUSE (First, LaVern R Fuller Middle, Last, Suffix) If wife, give maiden name 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Dora Anna Mathilda Marxen 16b. LICENSE NO. 1448 16d. CEMETERY, CREMATORY OR OTHER LOCATION Grand Island City Cemetery CITY / TOWN Grand Island STATE Nebraska 17a, FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, S Apfel Funeral Harne, 1123 W. 2nd, Grand Island, Nebraska 3. DATE OF DEATH (Mo., Day, Yr.) April 12, 2018 6. DATE OF BIRTH ( November 30, 1926 o., Day, Yr.) 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Son 16c. DATE (Mo, Day, yr.) April 17, 7201 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter they chain Of events -- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, - respiratory arrest, Or Ventticular 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) Recurrent CVA disease or condition resulting in death) 201803685 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH ✓J STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES APPROXIMATE INTERVAL onset to. death Years I - IY u1 U 3 0. E 0 V at Seaudnualty list conditions, if any, leading to the cause Hated' on line a DUE TO, OR AS A CONSEQUENCE OF: b)Atherosclerosis onset to des Years Enter the UNDERLYING CAUSE ( disease or injury that initiated res DUE TO, OR AS A CONSEQUENCE OF: C) onset to death the u aing . ,n death) ; DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. HTN Hyperlipidemia, Alzheimers Disease 20. IF FEMALE: ❑ ❑ Not pregnant past year Pregnant at time of death . ❑ Not Not pregnant, but pregnant within 42 days of death pre gnant, but pregnant: 43 days to 1 year before death ❑ Unknow g pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? < ❑ YES ❑ NQ 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE ; 3a. DATE OF DEATH (Mo., Day, Yr.) April 12, 2018 3b. DATE SIGIiIED (Mo., Day, Yr.) Aeril 16 2018 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) Shawn $. Lawrence, MD 25. DID TOBACOO USE CONTRIBUTE TO THE DEATH? ❑ YES El NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Shawn S. Lawrence, MD, 2201 N Broadwell Ave., Grand Island, Nebraska, 68803 J 28a. REGISTRAR'S SIGNATURE /(- `� -„ 22b. TIME OF INJURY 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22e. DESCRIBE HOW INJURY OCCURRED 23c. TIME OF DEATH 06:32 PM 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 21b. IF TRANSPORTATION INJURY Q Driver /Operator 0 Passenger 0 Pedestrian Other (Specify) 4a. BATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BE ❑ YES NO EN CONSIDERED? 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 Tide) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO April 18, 2018 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑YES ❑ NO 28b. DATE FILED BY REGISTRAR #Mu., Day, Yr.)