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STATE OF NEBRASKA
<br />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 />DATE OF ISSUANCE
<br />12/10/2018
<br />LINCOLN, NEBRASKA
<br />201904867 RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTHAND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<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. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Debra Joan Harders
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 1, 2018
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER I DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Grand Island, Nebraska
<br />(Yrs.)
<br />64
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />November 12, 1954
<br />7. SOCIAL SECURITY NUMBER
<br />508-78-1991
<br />Ba. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (t% not Institution, give street and number)
<br />CHI Health St. Francis
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) I8d. COUNTY OF DEATH
<br />Gran:: island 53803 Hal!
<br />t
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Wood River
<br />9d. STREET AND NUMBER
<br />1901 North Burwick Road
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />9g. INSIDE CITY LIMITS
<br />0 YES ® NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />David Harders
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Ronald Campbell
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Evelyn Morosic
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />David Harders
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Nicholas D. Tank
<br />16b. LICENSE NO.
<br />1478
<br />16c. DATE (Mo., Day, Yr.)
<br />December 6, 2018
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />St. Mary's Cemetery Wood River Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />ADfel Funeral Home, 1123 W. 2nd. Grand Island. Nebraska
<br />17b, Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />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,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Cardiopulmonary Arrest
<br />disease or condition resulting
<br />onset to death
<br />90 Minutes
<br />n death( DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b) Hypertension, Hypothyroidism
<br />any, leading to the cause listed
<br />line
<br />onset to death
<br />Years
<br />on a.
<br />UUE 10, v/f AS A i:ON3EUUENc,E Or:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that initiated
<br />ut:zut ..,:alh
<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 -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Breast Cancer More Than 20 Years Ago
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES 0 N
<br />20. IF FEMALE:
<br />® Not pregnant within past year
<br />Pregnant at timeof death ❑ ea
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑Accident ❑Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />EiPassenger
<br />21c. WAS AN AUTOPSY PERFORMED?'
<br />❑ YES ®NO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />Side Could not be determined
<br />❑uic 0
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 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 />DYES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />.3 w
<br />23a. DATE OF DEATH (Mo., Day, Yr.)Z
<br />December 1, 2018
<br />0 `z z
<br />U
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />3 z
<br />1 21
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 3, 2018
<br />23c. TIME OF DEATH
<br />07:55 PM
<br />K
<br />Z = K y
<br />E y z
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />g ¢ O
<br />0O
<br />g
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Title)
<br />Thomas F Werner, MD
<br />'o' w z O
<br />w z p
<br />o O
<br />0 a
<br />24e. On the basis of examination and/or investigation, 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?126a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?r 26b. WAS CONSENT GRANTED?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN II ❑ YES ® NO I Not Applicable if 26a is NO 0 YES In NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Thomas F. Werner, MD, 810 North Diers Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 7, 2018Co
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