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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 11/6/2017 LINCOLN, NEBRASKA 201901351 A STANLEY S. • OPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH To be completedlverified by: FUNERAL DIRECTOR I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Mary Ann Huebner 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) October 24, 2017 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,, Da Yr.) Fullerton, Nebraska (Yrs.) 84 MOS. DAYS HOURS MINS. February 28, 1933 7. SOCIAL SECURITY NUMBER I 507-U-7277 8a. PLACE OF DEATH HOSPITAL i i Inpatient GTHER Fl Nursing Home/LTC D. Hospics Facility 8b. FACILITY -NAME (If not Institution, give street and number) Good Samaritan Society -Wood River 0 ER/Outpatient 0 Decedent's Home 0 DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Wood River 68883 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2415 S. August St 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH 0 Married ❑ Never Married ❑:Married, but separated, ® Widowed ❑ Divorced 0 Unknown 1Gb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Roderick D Huebner 11. FATHER'S -NAME (First, Middle, Last, Suffix) John Tarnick 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Dorothy Cuba 13. EVER IN U.S; ARMED FORCES? Give dates of service if Yes. (Yes, No, orunk.) NO 14a. INFORMANT -NAME Gavle Woods 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ❑ Burial 0 Donation 16a. EMBALMER -SIGNATURE Patricia R. Curran 16b. LICENSE NO. 1092 16c. DATE (Mo., Day, Yr.) October 30, 2017 ® Cremation 0 Entombment ❑ Removal : 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Curran Funeral Chapel. 3005 S. Locust St.. Grand Island, Nebraska 17b. Zip Code 68801 0- CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 1 1S. PART I. Enter the Chain of events --diseases, injuries, or complications -that directly causrd 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 it necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Acute On Chronic Systolic Congestive Hear Failure onset to death , Days in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list Conditions, if b) lschemic Cardiomyopathy any, leading to the cease tinted. on tine a. onset to death 'd Years DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE C) Coronary Artery Disease tdisease or injury that initiated onset to death Years the svemsresuhin9 in death) c 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. COPD, Hypertension,hyperlipidemia,chronic Kidney Disease, Atrial Fibrillation 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? 0 YES ® NO 20. IF FEMALE: 0 Not pregnant within past year Pregnant at time of death El Pregnant 21a. MANNER OF DEATH ® Natural 0 Homicide Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator E-.] 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 0 unknown if pregnant within the past year Suicide 0 Could not be determined ❑ 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 ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE Y 23a. DATE OF DEATH (Mo., Day, Yr.) October 2#,'2017 To be completed by CORONER'S PHYSICIAN or COUNTY ATT( RNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 124b. TIME OF DEATH Y23b e I rez he Tr t',OJNNEn ,i.: , .._„ `^j , Z� i i�ViC /)F UEA 117 October 26, 2017 I _ 12:30 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD O x c s 3d. To the best of my knowledge, death occurred at the time, date and place and due to the causes) stated. (Signature and Title) Jay C. Anderson, 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. bID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES 0 NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR ISSUE a • ATION BEEN CONSIDERED? ❑ YES Ell NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, e8803 28a. REGISTRAR'S SIGNATURE /[ I �) 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) November 2, 2017 Q (31