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yriQ STATE OF NEBRASKA alikittfto a.tS il. 11. llti _mtzwzrjf 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 7/20/2018 LINCOLN NEBRASKA CERTIFI 201804671 RUSSELL FOSLER INTERIM ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CATE OF DEATH 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Audrey Lynn Howard 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Imperial, N ebraska 7. SOCIAL SECURITY NUMBER 507 -50 -3429 8t2. FACILITY - NAME (If not Institution, give street and number) CHI Health St. Francis 9a. RESIDENCE -STATE '< Nebraska 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married Ea 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 DISPOSITION E Burial ❑ Donation ❑ Cremation ❑ Entombment Removal '❑ Other (Specify) in death) Sequelittally list eonditlone, if any, leading totheCapse listed: on line a. 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death Nat pregnant,but pregnant within 42 days of death ❑ Not pregnant,tflit pregnant 43 days to 1 year before death ❑ Unknow if pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? ] YES (Q NO 23a. DATE OF DEATH (Mo., Day, Yr.) July 9, 2018 23b, DATE SIGNED (Mo., Day, Yr.) July 11 2018 C O. W J a+ g O $ a 0 3d. To the best of my knowledge, death occurred at the time, date and place to 2 Y and due to the cause(s) stated. (Signature and Title) 3 * W Z John A. Wagoner, MD u, .. 2 5. DID TOBACCO USE:: CONTRIBUTE TO THE DEATH? ❑ UNKNOWN ❑ YES ❑ NO a] PROBABLY 1 .28a. REGISTRAR'S SIGNATURE 22b. TIME OF INJURY 23c. TIME OF DEATH 03:47 PM 5a. AGE - Last Birthday (Yrs ) 77 9b. COUNTY Hall 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 5b. UNDER 1 YEAR MOS. 9d. STREET AND NUMBER 1920 Sagewood Ave 16a. EMBALMER-SIGNATURE Stacie L. Ruiz DAYS 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 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 9e. APT. NO. 21ti. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger 0 Pedestrian Other (Specify) 24tt. DATE S IGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES E NO 9f. ZIP CODE 68803 10b. NAME OF SPOUSE (Firs Clayton Green Middle, Last, Suffix) If wife, give maiden name, 11. FATHER'S -NAME (First, Middle, Last, Suffix) Joseph Bailey 1 12. MOTHER'S-NAME (First, Middle, Maiden Surname) Zella Harris 14a. INFORMANT-NAME Valerie Galvan 16b. LICENSE NO. 1495 17a. FUNERAL HOME N AME AND MA LING 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 I. 3. DATE OF DEATH (Mo., Day, Yr.) July 9, 2018 6. DATE OF BIRTH (Mo., Day, Yr.) ;. November 20, 1940' 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT,. Niece 16c. DATE (Mo., Day, Yr.) ". July 12, 2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Cemetery CITY / TOWN Grand Island STATE Nebraska 17b. Zip Code 68501 CAUSE OF DEATH (See instructions and examples) ts; PART I. Enter the :Chain of events -- diseases, injuries, or complications -that directly caused the death. 00 NOT enter terminal events such as cardiac arrest, tespiratofyarreet, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line,Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a)Small Cell Carcinoma Of The Lung disease or condition resulting onset to death 15 Months APPROXIMATE INTERVAL DUE TO, OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease of injury that initiated;:; onset to death the events resalb mg at death) LAST€ DUE TO, OR AS A CONSEQUENCE OF: d) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES E NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? ❑ YES ❑ 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 8, NUMBER, APT.NO. CITY/TOWN STATE 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD .. 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) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print John A. Wagoner, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803 28b. DATE FILED BY REGISTRAR (Me,, Yr.) July 13, 2018