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<br />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 IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />5/17/2018
<br />LINCOLN, NEBRASKA
<br />201808268
<br />Ix
<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 />To completed/verified by: FUNERAL DIRECTOR 1
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Martha Josephine Rief
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />May 7, 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 />Chicago, Illinois
<br />(Yrs.) :
<br />94 ,
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />August 27, 1923
<br />7. SOCIAL SECURITY NUMBER
<br />350-14-5194
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER El Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Tiffany Square Care Center
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<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 />4463 S. Locust St.
<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 El Married 0 Never Married
<br />❑Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Clarence :: Rief
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Martin Shuminas
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Josephine Bachulis
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) No
<br />14a. INFORMANT -NAME
<br />Carol Johnson
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />bli Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L. Ruiz
<br />16b. LICENSE NO.
<br />1495
<br />16c. DATE (Mo., Day, Yr.)
<br />May 11, 2018
<br />❑Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Grand Island City Cemetery Grand Island 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 />To be completed by: CERTIFIER
<br />14. 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, ' APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on s line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Cardiorespiratory Arrest
<br />disease or condition resulting
<br />onset to death
<br />Weeks
<br />in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially listcuntlitions, it b)Diastolic Congestive Heart Failure
<br />any,leading to the cause listed
<br />on line a.
<br />onset to death
<br />Weeks
<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 events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: -
<br />LAST d)
<br />onset to 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 />Peripheral Artery Disease, Gangrene Of Toe, Atrial Fibrillation, Diabetes, Hypertension, GERD, SSS With Pacemaker,
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES El NO
<br />20. IF FEMALE:';
<br />0 Not pregnant within past year
<br />0 Pregnant at time of deathPassenger
<br />21a. MANNER OF DEATH
<br />El Natural 0 Homicide `
<br />0 Accident 0 Pending Investigation
<br />2113. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ® NO
<br />© Not pregnant, but pregnant within 42 days of death
<br />Q Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />0 Suicide ❑could not be determined
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 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 />OYES ❑NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be complelOd by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />23a, DATE OF DEATH (Mo., Day, Yr.)
<br />May 7, 2018
<br />To be completed by
<br />CORONERS PI4YSI:SAN
<br />or COUNTY ATTOI:NEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />May 8, 2018
<br />23c. TIME OF DEATH
<br />03:20 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Kimberly A, Mickels, MD
<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 CONTRIBUTE TO THE DEATH?
<br />0 YES El NO 0 PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Kimberly A. Mickels, MD, 729 North Custer Avenue,
<br />26a. HAS ORGAN OR
<br />El YES
<br />a e ATION BEEN CONSIDERED?
<br />7 •
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />Grand Island, Nebraska, 68803
<br />1285. REGISTRAR'S SIGNATURE 13- /
<br />) (
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 15, 2018
<br />
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