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aacl St3l ilrs a 8$ $I T. $ atrehr STATE OF NEBRASKA )IY►„y�T��'�%t14i til F tyis. f9.74g 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 iiez..4 DATE OF ISSUANCE RUSSELL FOSLER 12/18/2018 201808138 U 813 OQ ASSISTANT STATE REGISTRAR V V DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH LINCOLN, NEBRASKA 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. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Jeanie Lynn Verba 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) November 1, 2018 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday Sb. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Dannebrog Nebraska (Yrs.) 70 MOS. DAYS HOURS MINS. December 29, 1947 7. SOCIAL SECURITY NUMBER :.. 506-58-9217 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility Sb. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis ER/Outpatient 0 Decedent's Home ❑ DOA ❑ 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 222 Arapahoe Ave 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES 0 NO 1Oa. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Vermaine Verba 11. FATHER'S -NAME (First, Middle, Last, Suffix) Harold Park 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Kathryn Klos 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or link.) No 14a. INFORMANT -NAME Vermaine Verba 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION 0 Burial 0 Donation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) November 6, 2018 ® Cremation ❑Entombment 0 Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon 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) Is. PART I. Enter the Chain of events- -diseases, Injuries, or complications -that directly caused the death.. DO NOT enter erminal events such as cardiac arrest, APPROXIMATE INTERVAL. respiratory arrest, or ventricular 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) Multi- Organ Failure disease or condition resulting onset to death 24 Hours in death) DUE TO, OR AS A CONSEQUENCE OF: sequentialyhst conditions, if b)Metastatic Lung Cancer - any,leading to the cause listed on linea onset to death 6 Months DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE C) disease or Injury that inItialed onset to death the events resulting in death) 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. Coronary Artery Disease, Atrial Fibrillation 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? 0 YES ® NO 20. IF FEMALE: ® Not pregnant within past year ❑ Pregnant at time of deathPassenger 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation 21h. IF TRANSPORTATION INJURY 0 Driver/Operator ❑ 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO o Not pregnant, gut pregnant within 42 days of death 0 Not pregnant,. but pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year : 0 Suicide Could not be determined ❑TO ❑Pedestrian ❑:Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE:. 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? AYES ONO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by F. MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) November 1, 2018 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 2, 2018 23c. TIME OF DEATH 09:15 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 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) Douglas Herbek, 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? ❑ YES 0 NO E PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ®NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Douglas Herbek, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATUREC----------- 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) November 7, 2018 "° c_- ----------