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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 7/10/2018 LINCOLN, NEBRASKA 2 V 19 V 4 34I4I ASSISTANT STATE REGISTRAR RUSSELL FDEPARTMENT 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 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Susan Renee Martens 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) July 1, 2018 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 51). UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)' Grand Island, Nebraska (Yrs.) 58 MOS. DAYS HOURS MINS. August 28, 1959 7. SOCIAL SECURITY NUMBER 505-88-1380 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility 8b. FACILITY UNMC -NAME (If not Institution, give street and number) 0 ER/Outpatient 0 Decedent's Home 0 DOA 0 Other(Specify) Omaha 68198 I8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH Douglas 9a.. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 3418 Tri Street 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY UMITS ® YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married ❑ Married, but separated 0 Widowed 0 Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Gaylord Martens 11. FATHER'S -NAME (First, Midc ie, Last, Suffix) Elvin Palu 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Caroljean Hunt 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk,) No 14a. INFORMANT -NAME Gaylord Martens 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION Ed Burial 0 Donation 16a. EMBALMER -SIGNATURE Stacie L. Ruiz 16b. LICENSE NO. 1495 16c. DATE (Mo., Day, Yr.) July 6, 2018 0 Cremation 0 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 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 1. 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 resp(ratdry 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) Immunoglobulin G Subclass 4 Systemic Sclerosing Disease , -t-ee, a n, cnnrlmno rvailool onset to death Years to deem) DUE TO, OR AS A CONSEQUENCE OF: Sequentially hat conditions, if ;::,b)Acute Hypoxic Respiratory Failure any, leading to the cause Muted onset to death Days on line a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Intrapulmonary Shunt (disease or injury that initiated onset to death Years the events reauhlog in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART (1. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Idiopathic Thrombocytopenic Purpura 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 0 Homicide El Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? 0 YES ®NO ❑ Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 41 days to 1 year before death 0 Unknown if pregnant within the past year 0 Suicide 0 Could not be determined ❑ Pedestrian 0 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 1Mo.. nay, Yr.l July 1, 2018 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNE ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) July 2, 2018 23c. TIME OF DEATH 04:59 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d, TIME PRONOUNCED DEAD 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Daniel M. Hershberger, 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? 0 YES NO ` 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ®YES 0 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Daniel M. Hershberger, MD, 985990 Nebraska Medical Center, Omaha, Nebraska, 68198 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) July 5, 2018 28a. REGISTRAR'S SIGNATURE � "� ' '� ,�' '