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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 5/13/2019 LINCOLN, NEBRASKA 201904.655 ASSISTANT STATEOSLER REGIISTRAR 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. DECEDENTS -NAME (First, Middle, Last, Suffix) Patricia Jeanne Brisnehan 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) April 27, 2019 4.CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER I DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Denver, Colorado (Yrs.) 74 MOS. DAYS HOURS MINS. February 23, 1945 7. SOCIAL SECURITY NUMBER 522-58-1118 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER E Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Tiffany Square Care Center ❑ ER/Outpatient 0 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 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2011 Stagecoach Rd 9e. APT. NO. 9f. ZIP CODE 19g. INSIDE CITY LIMITS 68801 ® YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Alan Brisnehan 11. FATHER'S -NAME (First, Middle, Last, Suffix) Francis K Bruggeman 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Kathryn U O'Connor 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) NO 14a. INFORMANT -NAME Alan Brisnehan 14b. RELATIONSHIP TO DECEDENT Spouse IF. METHOD OF DISPOSITION ® Burial ❑Donation 16a. EMBALMER -SIGNATURE Stacie L Ruiz 16b. LICENSE NO. 1495 16c. DATE (Mo., Day, Yr.) May 3, 2019 ❑Cremation 0 Entombment ❑:Removal <.❑ Othetispecify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn 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) ta. 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 ventnf,ular 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) Cardiopulmonary Arrest disease or condition resulting onset to death Months in death( DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b)CVA any, leading to the cause listed line onset to death >6months on a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Obesity (disease or injury that initiated <: onset to death >10 Years the events result ng in deem) ;. DUE TO, OR AS A CONSEQUENCE OF: LAST d)Obstructive Sleep Apnea onset to death >10 Years 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? 0 YES ® NO 20. IF FEMALE: = E Not pregnant within past year ❑Pregnant at time of death 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation 21b, IF, TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑YES ®NO 0 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 0NO 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.) April 27, 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.) April 30, 2019 23c. TIME OF DEATH 03:43 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. To the best of my knowledge, death occurred al the time, date and place and due to the cause(s) stated. (Signature and Title) Kenneth Vette), 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 E NO ❑ PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ENO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Kenneth Vette), MD, 2116 W Faid)ey #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) .. May 8, 2019