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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 /S THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />628
<br />LINCOLN/18/01
<br />, NEBRASKA
<br />STANLEY . COOPER
<br />ASSISTA STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />18 07149
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death,
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Judith Briggs
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />May 31, 2018
<br />4. CITY. AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.),
<br />San Bernardino, California
<br />(Yrs.)
<br />78
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />June 9, 1939
<br />7. SOCIAL SECURITY NUMBER
<br />351-30-3853
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />52 Kuester
<br />0 ER/Outpatient ® Decedent's Home
<br />0 DQA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />52 Kuester
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS'
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Richard Allen Briggs
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Eskil Anderson
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Berneice Keene
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Richard Allen Briggs
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑ Burial '' ❑Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />June 1 2018
<br />®Cremation 0 Entombment
<br />❑;Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<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 />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART L Enter the chain of events- -diseases, injuries, or complications -that directly caused the death; DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Liver Carcinoma
<br />disease or condition resulting
<br />onset to death
<br />3 Months
<br />in death)
<br />DUE TO, OR A`: A CONSEQUENCE OF:
<br />Sequentially hsttonditions, if b) Probable Pancreatic Carcinoma
<br />any, leading to the cause listed'
<br />on line' a.
<br />onset to death
<br />3 Months
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury, that initiated
<br />onset to death
<br />the eventsresulthlij in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onsetto death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />H/O Breast Cancer, Cushings Disease, Hypertension, Mild Dementia, Carotid Artery Disease, H/0 CVA, Osteoporosis, Lumbar
<br />Spine Stenosis, Vitamin D Deficiency
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES ® NO
<br />20. IF FEMALE: '<
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death❑
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />-
<br />0 YES ®NO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />0 Suicide ouidnot be determined 0 C
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home,
<br />farm, street, factory, office building,
<br />construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be complete d by
<br />MEDICAL CERTHIER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)z Y
<br />May 31,2018 sgz
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />June 1, 2018
<br />23c. TIME OF DEATH
<br />01:48 AM
<br />I L
<br />J
<br />E 2
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />22d. To the best
<br />and due
<br />Kimberly
<br />of my knowledge, death occurred at the time, date and place
<br />to the cause(s) stated. (Signature and Title)
<br />A. Mickels, MD
<br />y
<br />' tit z O
<br />o Q 8
<br />~ 0 o
<br />o
<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 />25. DID TOBACCO USE
<br />0 YES Il NO
<br />CONTRIBUTE TO THE DEATH?
<br />0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ❑ NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Kimberly A. Mickels, MD, 729 North Custer Avenue,
<br />Grand Island, Nebraska, 68803
<br />28a, REGISTRAR'S SIGNATURE /y 28b. [DAT: FILED BY REGISTRAR (Mo., Day, Yr.)
<br />CGI
<br />(�� June 5, 2018
<br />
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