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iiteraPitioialfinitir STATE OF NEBRASKA forldtaMMIMA 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 11/15/2017 LINCOLN, NEBRASKA age 2 018 0 7 4 5 3 STANLEY S. PER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH To be completed/verified by: FLJN£RAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Dorothy Lenora Sharp 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) November 5, 2017 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Grand Island, Nebraska (Yrs.) 96 MOS. DAYS HOURS MINS. October31, 1921 7. SOCIAL SECURITY NUMBER 505-12-2810 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER ® Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Brookefield Park 0 ER/Outpatient 0 Decedent's Home 0 DOA 0 Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) St. Paul 68873 r 8d. COUNTY OF DEATH Howard 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9e. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 3990 W. Capital 9e. APT. NO. #110 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married ❑ Married, but separated 0 Widowed ❑ Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Carl Sharp 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Richard L Rauert Ella Johanna Voss 13. EVER IN U.S ARMED FORCES? Give dates of service if Yes. (Yes, No, or Link.) No 14a. INFORMANT -NAME Barbara A Watton 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ❑ BUYaI 0 Donation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) November 6, 2017 ® Cremation 0 Entombment ❑ Removal 0 Other (Specify) 16d. CEMETERY, 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) Apfel Funeral Home. 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTtFIER it. PART I. Enter the chain of events --diseases, injuries, , r complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Einer onlyone cause: on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Cardiac Arrhythmia disease or condition resulting onset to death Minutes in death) DUE TO, OR AS A CONSEQUENCE OF: seauantiaaylist <onditions,it b) Myocardia! Infarction any, leading to the cause listed':, onset to death` Hours on line a DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Coronary Artery Disease (disease or Injury that initiated. onset to death Years the events resulting in dealt) DUE TO, OR AS A CONSEQUENCE OF: LAST: - d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Congestive Heart Failure 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20.1F FEMALE: -' 0 Not pregnant within past year 0 Pregnant at time of death 21a. MANNER OF DEATH ® Natural 0 Homicide Accident Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 0 Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pfegnam 43 days to 1 year before death 0 Unknown B pregnant within the past year 0 ❑ 0 Suicide 0 Could not be determined 0 Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? . ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) November 5, 2017 To be completed by � CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) November 6, 2017 23c. TIME OF DEATH 12:03 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD II 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Jared Kramer, MD 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) 26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES 0 NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR ISSUE DONATION BEEN CONSIDERED? 0 YES 7 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jared Kramer, MD, 1113 Sherman St., PO Box 406, St. Paul, Nebraska, 68873 28a. REGISTRAR'S SIGNATURE j) /(_ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) November 7, 2017