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WHEN'' THIS I' 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 le DATE OF ISSUANCE RUSSELL FOSLER 1/14/2019 201 9 0 i1 9 i �j ASSISTANT STATE REGISTRAR �7 V �J Kr y� 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) Esther Eloise Waller 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) January 8, 2019 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.) Hastings, Nebraska (Yrs.) 95 MOS. DAYS HOURS MINS. June 7, 1923 7. SOCIAL SECURITY NUMBER 508-36-2767 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 0 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 1703 S. Arthur St. 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married ❑Married, but separated ® Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Tannies Waller 11. FATHER'S -NAME (First, Middle, Last, Suffix) Archie Murrish 12. MOTHER'S -NAME (First, Middle, Maiden Surname) ( Martha Kenyon 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) NO 14a. INFORMANT -NAME Gary John Waller 14b. RELATIONSHIP TO DECEDENT Son 15. METHOD OF DISPOSITION ® Burial 0 Donation 16a. EMBALMER -SIGNATURE Stacie L Ruiz 16b. LICENSE NO. 1495 16c. DATE (Mo., Day, Yr.) January 14, 2019 ❑ Cremation 0 Entombment ❑ Removal ; 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Cemetery Grand Island 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) 18. PART 1. Enter the chain of events --diseases, injuries, or complicationsdhat 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. Enter only one cause on a line. Add additional lines N necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting onset to death 1 Day in death) `. DUE TO, OR AS A CONSEQUENCE OF: - Sequentially list conditions, if;. b)Metastatic Lung Adenocarcinoma - any, leading to the cause listed onset to death' 11 Months' on line a. 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 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Myasthenia Gravis 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? 0 YES ® NO 20. IF FEMALE::: ❑ Not pregnant within past year 0 Pregnant at time of death 21a. MANNER OF DEATH ® Natural ❑ Homicide 0 Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ®NO ❑ Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown If pregnant within the past year 0 Suicide 0 Could not be determined 0 Pedestrian 0 Other (Specify) 21 d. 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.) January 8, 2019 To be completed by CORONER'S PHYSICIAN of COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) January 10, 2019 23c. TIME OF DEATH 10:20 AM 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) Isaac J. Berg, 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 cau e(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES NO®❑PROBABLY ❑UNKNOWN 26a. HAS ORGAN OR • • ATION BEEN CONSIDERED? 0 YES 7 • 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand Nebraska, 68803 28a. REGISTRAR'S SIGNATURE - 28b. DATE FILED BY REGISTRAR (Mix, Day, Yr.) January 10, 2019