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tem Intir 8d #(9` 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 4/4/2017 LINCOLN, NESRA$KA 201807780 ate STANLEY S. COOPER 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: FUNERAL DIRECTOR 1. DECEDENTS -NAME (First, Middle, Last, Suffix) ' Darleen Joan Walker 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) March 25, 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.) Custer County, Nebraska (Ym•) 91 MOS. DAYS HOURS MINS. August 29, 1925 7. SOCIAL SECURI iY NUMBER 505-24-1235 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (11 not Institution, give street and number) Tiffany Square Care Center ❑ ER/Outpatient 0 Decedent's Home 0 DOA 0 Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 119E 19th Street 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married butrseparated' ❑ Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name James Edward Walker 11. FATHER'S -NAME (First, Middle, Last, Suffix) Clarence Munnell 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Theresa Juel 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk) No 14a. INFORMANT -NAME James Edward Walker 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial 0 Donation 16a. EMBALMER -SIGNATURE Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) March 29, 2017 ❑ Cremation ❑Entombment ❑ Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral' Home. 2929 S. Locust Street. Grand Island. Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) Se. PARTY. Enter the Chain of events --diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventrlCular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting APPROXIMATE INTERVAL onset to death < 1 Week in death) Sequentially list Conditions, if any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: <'b)Cerebral Vascular Accident onset to death > 1 Week on linea. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE D) Congestive Heart Failure (disease or injury that initiated the events resultlltg in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death > 1 Week onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO feted by: CERTIFIE ❑❑❑❑❑ $ 9 Q % S 1 O 1; m D O r ' m :1; ea-, 3 m R ro 3 5 � + 6 a n � p � 21a. MANNER OF DEATH El Natural 0 Homicide 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO ❑ Accident 0 Pending Investigation Suicide Could not be determined ❑ ❑ 0 Pedestrian ❑ 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 0 N 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.) March 25. 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.) March 28 2017 23c. TIME OF DEATH 05:15 PM 24c. PRONOUNCED DEAD (M..., Day, Yr. 24d. TIME PRONOUNCED DEAD r 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) Jennifer L. Brown, 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) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES NO 0 PROBABLY 0 UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jennifer L.Brown, MD, 729 NorthCuster Avenue, 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES 50 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES 0 NO Grand Island, Nebraska, 68803 a. REGISTRAR'S SIGNATURE 28/L� ` Y - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) March 31, 2017