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1 To Be CompletedNerified by: FUNERAL DIRECTOR r..... '- . 5. ... va a /4-I"a. I1 1. DECEDENTS -NAME (First, Middle, Lest, Suffix) Connie Jo Reeder 2. SEX . Female 6Y=YlJ4LJt 7.1 3. DATE OF DEATH (Mo.,Day,Yr.) October 29, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Lexington, Nebraska 6s. AGE -Last Birthday (Yrs.) 65 6b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) March 6, 1947 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -62 -9467 Ba. PLACE OF DEATH HOSPITAL: © Inpatient OTHER: C7 Nursing Home/LTC ❑ Hospice Facility Bb. FACILITY -NAME (If not Institution, give street and number) Nebraska Medical Center 8e. CITY OR TOWN OF DEATH (Include Zip Code) Omaha 68198 ❑ ER/Outpatient ❑ Decedents Home 0 DOA ❑omer(specity) 8d. COUNTY OF DEATH Dougles 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Wood River 9d. STREET AND NUMBER 1201 Pine Street P.O. Box 241 Se. APT. NO. 91. ZIP CODE - 68883 9g. INSIDE CITY LIMITS ® Yes ❑ No 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Nib. NAME OF SPOUSE (First, Middle, Last, Suffix) I wife, give maiden name. Richard Reeder 11. FATHER'S -NAME (First, Middle, Last, Suffix) Virgil Carl. McElhinny+ 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Delia Elizabeth Carpenter 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes, (Yes, No, or Unk.) No 14a. INFORMANT -NAME I Richard Reeder 14b. RELATIONSHIP TO DECEDENT Spouse 16. METHOD OF DISPOSITION ❑burial ❑Donation ®Cremation IDEmombment ❑Removal ❑rflhedspecny) 16a. EMBAL 10 TURE / 16b. LICENSE NO. Id tz 3 16e. DATE (Mo., Day, Yr.) November 1, 2012 16d. CEMETE CREMATORY OR OTHER LOCATION CITY/TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 117b. Zip Code Apfel Funeral Home, 1123 W. 2nd, Grand island, Nebraska 1 68801 To Be Completed by: CERTIFIER CAUSE OF DEATH (See instructions and examples) ta. PART I. Enter the ream of events - diseases, Inhalers, or complications. that directly caused the death. 00 NOT reaplratory arrest or venMSUler fibrillation without showing the etiology. DO NOT ABBREVIATE Enter only one IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final !f� I ' n • �. � y- V ( _,� l disease or condition resulting a) ! % 1 / i �S in death) enter terminal meets such as cardiac attest, APPROXIMATE INTERVAL cause one line, Add additional lime N necessary, Onset to do ( f . - /7 1 `- �it \' _...C. DUET OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) ^ � `l e C\ 1 1 4- any,leading to the cause listed r / �� on line a. DUE TO, OR AS A C OF: 0 p p p� /►'� ( '' ( � , Enter the UNDERLYING CAUSE e) �' l �- Pa. 1 �" � ✓ (� V �1�- -� `�" I (disease or injury that Initiated onset t t death T the events resulting in death) DUE e o( TOO, OR AS A CONSEQ ENCE OF: ` 1 onset to death �� LAST d) 1 k 1 V ` V /1 V - 12 y R-,.\\ 18. PAR 1.r THE SIGNIFICANT FlCANT �DITI� - t c; itd / ,te t�he butt ul! g�the underlying ing case give R I. Il o' ` C 0 ` l V 1 / J fret c ` Y -- 1 - r 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 20. IF FEMALE: of pregnant within past year ❑ Pregnant at time of death Not pregnant, but ❑ pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑Unknown if pregnant within the past year 21a, NNER OF DEATH tr,WNatural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide 0 Could not be determined 216. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21e. WAS AN AUTOPSY RMED? ❑ YES 210 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 22e. PLACE OF INJURY -At home, farm, street, factory, office building, construction 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, rr, bur r 0 ( L /f�Q( ...z m' 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH m i o.„., o U o W 23b. DATE SIGNED (Mo., D Yr.) - ' c. . 23r . TIME O DEATH + 7-• ?0 m i T O E Na Z 24c. PRO ONCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD M 23d. To the best of my knowt ath oecu at the time, date and place a nd due to the a s ( Sign cure an Tde) u W z 0 a E,3 Lc 0 Lb 0 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. DfD J DBACCO USE CONTRIBUTE TO THE DEATH? YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES cE`NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO 0 YES ❑ NO 27 A N A ME, AND ADDRESS OF ERTIFI ype or 4 16\ 4b - MD 987680 NMC Omaha, NE 68198 P 28a. REGI TRAMS SIGNATURE /aA'� ateralgf>r Cs9 e.er 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) NON 0 2 2012 I STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 1 D , This certifies this document to be a-true copy of an original record on file with Vital Statistics, Douglas County Health Dept,, Omaha, Nebraska. Certified copies must have a raised seal in the area to the left. Reproduction -of this green cer are not legal copies. KV s , DateIssued: ®2 2012 Registrar: