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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE 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`•kECbRDSe i. wt t•. DATE OF ISSUANCE 10/22/2015 LINCOLN, NEBRASKA 201905219 STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AAP :HUMAN S,ERtj7CES' STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 15 06023 To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Marianne Wilson 2. SEX3.'D(rT£ Female • OE DEATH (Mo., Day, Yr.) ,, October 1.5,2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER1 DAY. , 6. qAT OF BIRTH (Mo., Day, Yr.) Valley County, Nebraska (Yrs.) 72 MOS. DAYS HOURS MINS.' May 28, 1943 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER E Nursing Home/LTC 0 Hospice Facility 508-54-2578 8b. FACILITY -NAME (If not Institution, give street and number) Good Samaritan Society -Wood River 0 ER/Outpatient ❑ Decedent's Home 0 DOA 0 Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Wood River 68883 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Wood River 9d. STREET AND NUMBER 1401 East Street 9e. APT. NO. 9f. ZIP CODE 68883 9g. INSIDE CITY LIMITS ® YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married 0 Married, but separated 0 Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Hal Francis Wilson 11. FATHER'S -NAME (First, Middle, Last, Suffix) Leonard Ptacnik 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Edna Smolik 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Hal Francis Wilson 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial 0 Donation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) October 17, 2015 ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING 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) To be completed by: CERTIFIER 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, APPROXIMATE INTERVAL respiratory 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) progressive Dementia disease or condition resulting onset to death Years n death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) any, leading to the cause listed onset to death on line a. DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death Enter the UNDERLYING CAUSE c) I I (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST1 d) I 1 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Seizure Disorder 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES 0 NO 20. IF FEMALE: E Not pregnant within past year Pregnant at time of death 21a. MANNER OF DEATH E Natural 0 Homicide 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? 0 YES ENO 0 0 Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death Unknown if the ❑ Accident ❑ Pending Investigation 0 Suicide ❑ Could not be determined 0 Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO ❑ pregnant within past year 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 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY ;3a. DATE OF ue'ATH (bio., Day, Yr.) October 15, 2015 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORN'Y ONLY 24a. DATE SIGNED (Ma., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) October 16, 2015 23c. TIME OF DEATH 07:08 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Jane A. McDonald, 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 E NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR ISSUE a • ATION BEEN CONSIDERED? Ilj 0 YES El NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 03 28a. REGISTRAR'S SIGNATURE _ � �� _ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I October 19, 2015