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STATE OF NEBRASKA 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 11/15/2018 LINCOLN, NEBRASKA RUSSELL FOSLER 2019009aG AISTANT STATE REGISTRAR DEPARTMENTOFHEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1814363 Pursuant to section 30-2413, demands for notice which may affect the estate of tt e 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) Gail Marie Trobough 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) November 5, 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.) Kearney, Nebraska (Yrs.) 60 MOS. DAYS HOURS MINS. January 5, 1958 7. SOCIAL SECURITY NUMBER 505-82-6905 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) 2515 W Anna Street 0 ER/Outpatient ® 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 Sa. REQ DENCE CT.`. -:E lab, GOUNT( 13c. ITY On TO JN Nebraska I Hall l Grand Island 9d. STREET AND NUMBER 2515 W Anna Street 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL 0 Married, STATUS AT TIME OF DEATH ® Married ❑ Never Married but separated 0 Widowed ❑ Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Larry Lee Trobough 11. FATHER'S -NAME (First, Middle, Last, Suffix) Edward Schlund 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Hazel Wolbing 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Link.) No 14a. INFORMANT -NAME Larry Lee Trobough 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑Burial 0 Donation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) November 7, 2018 ®Cremation ❑Entombment ❑f 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) 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, 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) Respiratory Failure disease or condition resulting onset to death Hours In death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) Metastatic Follicular Lymphoma any, leading to the cause listed on line a. onset to death Years 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: wsT 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. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES Ej NO 20. IF FEMALE: ':': ® Not pregnant within past year ❑ Pregnant at time of death 21a. MANNER OF DEATH ® Natural ❑ Homicide ElAccident ElPendingInvestigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator El Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year ❑ Suicide ❑:Could not be determined 9 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.) November 5, 2018 To be completed by CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) November 7, 2018 23c. TIME OF DEATH 01:15 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 causes) stated. (Signature and Title) Katie L. Peters, Nurse Practitioner a 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 _ 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Katie L. Peters, Nurse Practitioner, 2116 W Saidley Ave Ste 400, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I' November 13, 2018