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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA 4WE NT OFHEALTHAND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY F ='0 i� 01 0""31 DATE OF ISSUANCE 09/29/2015 LINCOLN, NEBRASKA 201900997 • STANLEY S..COPPER ASSISTANSTATE REGISTRAR DEPART 1T l EALTH AND Hl1MAN S R1�ICE STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH tZq rr To be completed/verified by: FUNERAL DIRECTOR 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Janice Marie Thayer 2. SEX 3.3. 1« Female' �iL mat. 14 02321 77b DEATH (Mo., Day, Yr.) ', May 3 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 76 5b. UNDER 1 YEAR 5c. UNDER 1 DAY MOS. DAYS HOURS MINS. ^ 6; GATE OF BIRTH (Mo., Day, Yr.) June 18, 1937 7. SOCIAL SECURITY NUMBER 506-44-1105 8b. FACILITY -NAME (If not Institution, give street and number) 2307 Stagecoach Road 8a. PLACE OF DEATH HOSPITAL 0 Inpatient ❑ ER/Outpatient ❑ DOA OTHER 0 Nursing Home/LTC 0 Hospice Facility ® Decedent's Home ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2307 Stagecoach Road 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS 0 YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married ❑ Married, but separated 0 Widowed 0 Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Ernest James Thayer 11. FATHER'S -NAME (First, Middle, Last, Suffix) Alfred Larson 12. MOTHER'S -NAME (First, Middle, Evelyn Andrews Maiden Surname) 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Ernest James Thayer 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION 0 Burial 0 Donation ❑ Cremation 0 Entombment 0 Removal 0 Other (Specify) 16a. EMBALMER -SIGNATURE Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) May 8, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION Grand Island City Cemetery CITY / TOWN Grand Island STATE Nebraska 17a. FUNERAL HOME NAME AND MAILING 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) To be completed by: CERTIFIER 18. PART I. 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 ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines a necessary. IMMEDIATE CAUSE: a)Adenocarcinoma Of Lung With Mets To Brain, Pleural Fluid, Bone And Pericardial Fluid IMMEDIATE CAUSE (Final di or condition resulting in death) APPROXIMATE INTERVAL onset to death 2 Years DUE TO, OR AS A CONSEQUENCE OF: Sequentially lin conditions, it b) any, leading to the cause listed on line a onset to death DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury that initiated 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. Hypertension, Osteopenia, Kyphosis 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: 0 Not pregnant within past year 0 Pregnant at time of death ❑ Not pregnant, but 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 21a. MANNER OF DEATH ® Natural 0 Homicide ❑ Accident 0 Pending Investigation 0 Suicide ❑ Could not be determined 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger 0 Pedestrian 0 Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? 0 YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES 0 NO 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 23a. DATE OF DEATH (Mo., Day, Yr.) May 3, 2014 23b. DATE SIGNED (Mo., Day, Yr.) May 13, 2014 23c. TIME OF DEATH 11:51 PM 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) Kimberly A. Mickels, MD 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.)/ 24d. TIME PRONOUNCED DEAD 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) 126a. HAS ORGAN OR ISSUE DONATION BEEN CONSIDERED? 0 YES El NO 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 Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, • - a, 68803 28a. REGISTRAR'S SIGNATURE 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES 0 NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) May 13, 2014 1