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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 /S THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 5/13/2019 LINCOLN, NEBRASKA 201903047 RUSSELL FOSLER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 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) Roberta Lee Filkins 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) May 2, 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,).. Grand Island, Nebraska (Yrs.) 75 MOS. DAYS HOURS MINS. August 12, 1943 7. SOCIAL SECURITY NUMBER 506-50-1836 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) 2504 W. Oklahoma Ave 0 ER/Outpatient ❑ Decedent's Home 0 DOA ®Other (Specify)Oaughtef'S Home 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIOENCEaSTATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Alda 9d. STREET AND NUMBER 23 Venus Street 9e. APT. NO. 9f. ZIP CODE 68810 9g. INSIDE CITY LIMITS E YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married ❑:Marded, but separated 0 Widowed 0 Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Donald Filkins 11. FATHER'S -NAME (First, Middle, Last, Suffix) William H Shaver 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Catherine Humphrey 13. EVER IN U.S_ ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Donald Filkins 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.) May 2, 2019 ® Cremation 0 Entombment ❑ Removal ❑ 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) 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 < 1 Week in death) DUE TO, OR AS A CONSEQUENCE OF: sequentially list conditions, it <': b)Metastatic Rectal Cancer any, leading to the: cause Listed' a. onset to death > 1 Year on line DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury that initiated: onset to death the events resulting m death) DUE TO, OR AS A CONSEQUENCE OF: 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. Atrial Fibrillation 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES E NO 20. IF FEMALE: ENot pregnantwithin past year 0 Pregnant at time of death 21a. MANNER OF DEATH E Natural 0 Homicide ❑ Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ENO 0 Not pregnant, but pregnant within 42 days or death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 0 Suicide 9 Could not be tlete minetl ❑ 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? I' ❑ 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.) Mav 2, 2019 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.) Mav 3, 2019 23c. TIME OF DEATH 09:50 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 and Title) Jennifer L. Brown, MD 24e. On the basis of examination and/or investiga ion, 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? 9 YES 9 NO 9 PROBABLY E UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 9 YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE +A'r 28b. DATE FILED BY REGISTRAR (Mo.r Day, Yr.) ;< ' May 7, 2019