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MN Attic, ♦ ..aa>s. 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 10/18/2017 LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Jean Michelle Rork STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 507 -80 -7730 8b. FACILITY -NAME (tt not Institution, oi',e street and number) 908 W. 15th Street 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or link...) No I te j 8c. CITY OR TOWN OF DEATH (Include Zip Code) c Grand Island 68801 9a, RESIDENCE -STATE Nebraska LL 9d. STREET AND NUMBER a 604 Linden Ave 10 a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married f D Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 5a. AGE - Last (Ws.) 61 Birthday 9b. COUNTY Hall 5b: UNDER 1 YEAR MOS. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient D ER/Outpatient ❑ DOA .a 11. FATHERS-NAME (First, Middle, Last, Suffix) d Jack Manning 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment Removal CI Other (Specify) IMMEDIATE CAUSE (Final disease or condition resulting to death):: DUE TO, OR AS A CONSEQUENCE OF: Begdet ttauIy list eotiditione, if i:b) any, leading to the cause listed s on line a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (diseaae er injury that initiated '?Win death) Q. l t EMALE: ® Not pregnant within pest year ❑ Pregnant at time of death .❑ Net tregnant;:but pregnant within 42 days of death ❑ Not pregnant but pregnant 43 days to 1 year before death ❑ UnRnowh if pregnant wNP i s the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. iNJURYAT WORK? DYES ❑NO 23a. DATE OF DEATH (Mo., Day, Yr.) October 6,1017 ,', 16a. EMBALMER - SIGNATURE Not Embalmed DAYS 9e. APT. NO. 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ Decedent's Home ® Other (Specify)Family Members Home 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 9f. ZIP CODE 68803 3. DATE OF DEATH (Mo., Day, Yr.) October 6, 2017 6. DATE OF BIRTH (Mo., Da June 13, 1956 Yr.) 9g. INSIDE CITY LIMITS D YES ❑ NO 10b. NAME OF SPOUSE (First, Darrell Rork Middle, Last, Suffix) If wife, give maiden name 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Beverly Wieman 14a. INFORMANT -NAME Darrell Rork 16b LICENSE NO. 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Westlawn Memorial Park Crematory Grand Island STATE Nebraska 7a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livingston - Sondermann Funeral Home. 601 N. Webb Road. Grand Island, Nebraska CAUSE OF DEATH (See instructionspnd examples) PARTI. Enter the chain 4f events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or vetttritotar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional tines if necessary. IMMEDIATE CAUSE: a) Lung Cancer Metastatic onset to death the events re LAST <' 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 1. 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22b. TIME OF INJURY 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 21b, IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger 0 Pedestrian Other(Specify) 24a. DATE. SIGNED (Mo., Day, Yr.) 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day Yr.) October 9, 2017 17b. Zip;Code 68803 APPROXIMATE onset to death 1 Year 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES RI NO 21 c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? ❑ YES D NO 24b. TIME OF DEATH u, o�c Y $#o. DA" Si1a xED (Lis., pe :) . , iAtE (...�.TH u z October 7, I 09:15 AM 0 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) Ryan Ram8ekers, MD • 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? gi YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Ryan Ralnaekers,; 2116 W. Faidley Avenue, Grand island, Nebraska, 68803 28a. RGISTRAR'S SIGNATURE 26a. HAS OR ❑ YES 20180E872 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH N OR TISSUE DONATION BEEN CONSIDERED? 10 No STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERV ICES 24c FRONO;JNCFD r F D (Mc.. Day Yr. )I 24d. TIME PRONOUNCED DEAD 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) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mo4 Oay, Yr.) October 12, 2017