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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 NEBRASKA DEPARTJIENT'OF.HEALTH AND • HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE 08/12/2013 LINCOLN, NEBRASKA 201902327 STANLEY COOPER ASSISTANT STATE+ REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES •- CERTIFICATE OF DEATH 13 03356 To be completed/verified by: FUNERAL DIRECTORI 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Velma Lee Dobesh 2. SEX - Female 3, DATE OF DEATH (Mo., Day, Yr.) August 6,;,2013 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.) Kamiah, Idaho (Yrs.) 73 MOS. DAYS HOURS MINS. October 11, 1939 7. SOCIAL SECURITY NUMBER 509-34-6270 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) 1147 S. Eddy ❑ ER/Outpatient ® Decedent's Home ❑ DOA 0 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 1147 S. Eddy 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married ❑ Married, but separated 0 Widowed ❑ Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Bernard Louis Dobesh 11. FATHER'S -NAME (First, Middle, Last, Suffix) Clarence Avis Wilson 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Eva Howell 13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Bernard Louis Dobesh 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial 0 Donation 16a. EMBALMER -SIGNATURE Daniel D Naranjo 16b. LICENSE NO. 1071 16c. DATE (Mo., Day, Yr.) August 10, 2013 ❑ Cremation ❑Entombment ❑ Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City 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 I 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, 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) End Stage Systolic Congestive Heart Failure disease or condition resulting onset to death Q >1 Years W In death( DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) Ischemic Cardiomyopathy any, leading to the cause listed Ilne onset to death = >10 Years V on a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Arteriosclerotic Cardiovascular Disease, Coronary Artery Disease (disease or injury that Initiated onset to death W >25 Years Er the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: LAST d)Chronic Kidney Disease 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. Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease Stage 3 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 0. IF FEMALE: 0 Not pregnant within past year Pregnant at time of death 0❑ 21a. MANNER OF DEATH ® Natural ❑ Homicide Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑YES ® NO 0 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 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 To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) August 6, 2013 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) August 8, 2013 23c. TIME OF DEATH 01:05 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 cause(s) stated. (Signature nd Title) Steven Husen, 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. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES 0 NO 0 PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR ❑ YES ISSUE DONATION BEEN CONSIDERED? 17 NO 26b. WAS CONSENT GRANTED? Not Applicable H 26a is NO 0 YES 0 NO fII 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, -• ka, 68803 28a. REGISTRAR'S SIGNATURE jo- 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I August 8, 2013