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STATE OF NEBRASKA /Y. 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 j DATE OF ISSUANCE 8/15/2019 LINCOLN, NEBRASKA 201905284 RUSSELL FOSLER ASSISTANT STATE REGISTRAR DEPARTMENT 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 deceae•ed are filed with' the county court in the county where the decedent resided at the lime of death. 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Fern Marie McGraham 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) August 5, 2019 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)'-.:. Gothenburg, Nebraska (Yrs.) 73 MOS. DAYS HOURS MINS. December 24, 1945 7. SOCIAL SECURITY NUMBER 506-62-0330 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) 413 E 7th St 0 ER/Outpatient E Decedent's Home 0 DOS. ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska ` 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 413E 7th St 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS 2 YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married ❑Married, but separated 0 Widowed 0 Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Martin Ronald McGraham 11. FATHER'S -NAME (First, Middle, Last, Suffix) Howard Doudna 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mary Lind 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Martin Ronald McGraham 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.) August 8, 2019 ® Cremation ❑Entombment ❑ Removal ❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Memorial Park Crematory Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston -Sondermann Funeral Home. 601 N. Webb Road, Grand Island, Nebraska 17b. Zip Code 68803 CAUSE OF DEATH (See instructions and examples) 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) Cardiac Arrest disease or condition resulting onset to death mdeafnl - DUE TO, OR AS A CONSEQUENCE OF: ' onset to death Sequentially list conditions, if . <'0) Hernia any, leading to the Cause listed " 'on linea.' DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury that initiated... onset to death the events resulting in death) LAST .DUE TO, OR AS A CONSEQUENCE OF: < ;d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. High Blood Pressure 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? E YES ❑ NO 20. IF FEMALE: ENot pregnant within past year 0 Pregnant at time of death 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident EIPending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E NO 0 Not pregnant, but pregnant within 42 days of death 0 Not pregnant, Iwt pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year 0 Suicide ❑ Could not be determined 0 Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES ❑ 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 ONO 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 23a. DATE OF DEATH (Mo., Day, Yr.) 2 ao ,1 24a. DATE SIGNED (Mo., Day, Yr.) August 8, 2019 24b. TIME OF DEATH Unknown 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH I i k c -,Z= 24c. PRONOUNCED DEAD (Mo., August 5,21i19 Day, Yr.) 24d. TIME PRONOUNCED DEAD I 10:15 PM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 'o' w 2 O „,'o p 8 g. 8 o 24e. On the basis of examination and/or the time, date and place and due Thomas J. Helget, Deputy d/ investigation, in my opinion death occurred at to the cause(s) stated. (Signature and Title)) County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES 0 NO 0 PROBABLY E UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES E NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Thomas J. Helget, Deputy County Attorney, 231 South Locust Street, Grand Island, Nebraska, 68801 28a. REGISTRAR'S SIGNATURE �f ' 28b. DATE FILED BY REGISTRAR {Mo., Day, Yr.) August 13, 2019