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WHEN < THIS -''' COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />201904 x62'
<br />RUSSELL FOSLEK
<br />ASMISFAN r STATE REGISTRAR
<br />DE.PARTMEN`t' OF HEALTII
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DATE OF ISSUANCE
<br />7/26/2019
<br />LINCOLN, NEBRASKA
<br />19 09233
<br />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.
<br />1. DECEDENT'S -NAME (First. Middle, Lest. Suffix)
<br />Dorothy Ann Pape
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day Yr.)
<br />Jul 19, 2019
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a, ADE • Last Birthday
<br />Sb. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Ord, Nebraska
<br />(Yrs.)
<br />90
<br />MOS. `DAYS
<br />l
<br />HOURS
<br />MINS.
<br />August 7, 1928
<br />7. SOCIAL SECURITY NUMBER
<br />508-30-3383
<br />Ea. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER ® Nursing Horne/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (If notInStltution, give Street and dumber)
<br />Good Samaritan Society -Grand Island Village
<br />0 ER/Outpadent 0 Decedent's Home
<br />0 DOA 0 Pinto (Specify),
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />6a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY 9c. CITY OR TOWN
<br />Hall Grand Island
<br />9d. STREET AND NUMBER ��d
<br />819 W 15th St
<br />9e. APT. NO.
<br />Of. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />RI YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH® Married 0 Never Married 11011. NAME OF SPOUSE (First, Middle, Latd, Suffix) If wife, give maiden name
<br />❑'Married, but separated 0 Widowed ❑ Divorced ❑ Unknown Robert Pape
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Michael Carkoski
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Anna Badura
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) No
<br />14e. INFORMANT -NAME
<br />Connie Cochnar
<br />14b. RELATIONSHIP TO DECEDENT
<br />Niece
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />18a. EMBALMER -SIGNATURE
<br />Matthew T. Myers
<br />16b. LICENSE NO.
<br />1411
<br />16c. DATE (Mo., Day, Yr.)
<br />July 24, 2019
<br />0 Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Livingston -Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska
<br />17b. Zip Cede
<br />68803
<br />CAUSE OF DEATH (See instructions and examelesi
<br />se. PART I. Enter the chain of events- -diseases, injuries, or cumplieetions-that directly caufed the death. DO NOT enter terminal events such as cardiac errest,
<br />APPROXIMATE INTERVAL
<br />respiratory arced*, or ventricular fibrillation without chewing the etiology. DO NOT ASSREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Stroke
<br />disease or condition resulting
<br />onset to death
<br />1 Year
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list ceintIltiene, if b)
<br />any, leading to the cause !Med
<br />onset to death
<br />on line a,
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or Injury that initiated':
<br />onset to death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST ;::: d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Condition, contributing to the death but not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES M NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />[] Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />Passenger
<br />210, WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant N days to 1 year before death
<br />❑ Unknown if pregnant within the Fast ye?r
<br />Suicide Couldnot be determined ❑ El i
<br />0 Pedestrian
<br />®Other (Speedy)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />0 YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />B
<br />230. DATE OF DEATH (Mo., Day, Yr.)
<br />July18,2019
<br />To be completed by
<br />CORONERS PHYSICIAN
<br />ocCOUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />s a
<br />1 0 z
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />July 22, 2019
<br />23c. TIME OF DEATH
<br />01:55 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.
<br />24d. TIME PRONOUNCED DEAD
<br />0 3d. To the best of my knowledge, death occurred at the time, date and place
<br />2 and due to the cause(*) suited. (Signature a id Tits)
<br />' Richard Fruehiino, MD
<br />24e. On the basis of examination and/or investiga ion, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES 1d NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a la NO 0 YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Typo or Print
<br />Richard Fruehling, MD, 2116 W Faidley #400, Box
<br />9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE /
<br />28b. DATE FILED BY REGISTRAR (Mo,, Day, Yr.)
<br />July 23, 2019
<br />
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