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I iiYrMVt�}�. N 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 7/11/2019 LINCOLN, NEBRASKA 201.9050 2 8RUSLER ASSISTA sT STATESELL RGISTRAR DEPARTNIENT OF IIEAL.TLI ANI) HUMAN SERVICES STATE OF NEBRASKA - DERARTMENT 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) Dorothy Marie Moeller 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) July 4, 2019 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last Birthday Sb, UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr,) Doniphan, Nebraska (Yrs.) 95 MOS. DAYS HOURS MINS. April 27, 1924 7. SOCIAL SECURITY NUMBER 507-24-3488 8a. PLACE QF DEATH HOSPITAL El Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not institution, give street and number) CHI Health St. Francis 0 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 Sa. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR. TOWN Grand Island 9d. STREET AND NUMBER 1922 W Division St Se. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES 0 NO 100. MARITAL STATUS AT TIME OF DEATH ❑ Married 0 Never Married ❑ Married, but separated) E Widowed 0 Divorced 0 Unknown 10b, NAME OF SPOUSE. (First, Middle, Last, Suffix) If wife, give maiden name Henry A Moeller 11. FATHER'S -NAME (First, Middle, Last, Suffix) William H Sundermeier 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Frieda Lena Obermeier 13. EVER tN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk,) No 14a. INFORMANT -NAME Gerri M Zrust 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION E Burial 0 Donation 16a. EMBALMER -SIGNATURE Matthew T. Myers 16b. LICENSE NO. 1411 16c. DATE (Mo., Day, Yr.) July 9, 2019 ❑ 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) Livinaston-Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska 17b. Zip Coda 68803 CAUSE OF DEATH,See instructions and examples) 16. PART I. Enter the: chain of events--diseaess, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular hbnllation without showing the etiology. DO NOT ABBREVrATE. Enter only one cause on a fine. Add additional lines it necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Acute Kidney Injury disease or condition resulting onset to death Days in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if. b)Hepatorenal Syndrome any, leading to the cause listed onset to death Days on line a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE C) Cirrhosis NOS (disease or Injury that Initiated onset to death Years the events resuhing In death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. chronic obstructive pulmonary disease, Chronic Diastolic CHF, Hypothyroidism 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ENO 20. IF FEMALE: 0 Not pregnant within past year ❑ Pregnant at time of death 21a. MANNER OF DEATH E Natural ❑ Homicide Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ENO ❑ Not pregnant, but poignant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death Unknown 0 pregnant within the past year ❑ Accident 0 0 ne 0 Suicide Could not be determid 0 Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO 0 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? AYES 0NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET L NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE A 23a. DATE OF DEATH (Mo., Day, Yr.) July 4. 2019 To be completed by CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH NI } i 23b. DATE SIGNED (Mo., Day, Yr.) July 5, 2019 23c. TIME OF DEATH 02:50 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD c q 0 2 9 152 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated, (Signature a td Tnio) Jay C. Anderson, MD 24e. On the basis of examination and/or Investigation, In my opinion death occurred at the rims, date and place and uue to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES 0 NO 0 PROBABLY E UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 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 Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE�' , e": ; :#"' - ~-m_ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) July 8, 2019 Exhibit "A"