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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AN,{ SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA-DEPAijt%�hl f,11)F, HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR V,Tw DATE OF ISSUANCE 201907958 �ST SA9f DFPA8TMEN1 LINCOLN, NEBRASKA , Hi4MAV .SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERri/10E i .'...14 � k CERTIFICATE OF DEATH 11/13/2012 EISTR,lvv s r >> • .6'Pey 44 ;:1204215 To be completed/verMied by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Dorothy Ann Stroh 2. SEX 1 • I Female , I 311)41Tf Ofi1EAT1+41o., Day, Yr.) ., t gvember 6, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.) Grand Island, Nebraska (Yrs.) 81 MOS. DAYS HOURS MINS. December 13, 1930 7. SOCIAL SECURITY NUMBER 508-30-8896 8a. PLACE OF DEATH )(OSPITAL ® Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center ❑ ER/ Outpatient 0 Decedent's Homs • 0 DOA 0 Other (Specify) 8c. CITY OR TOWN OF DEATH (include Zip Code) - Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 3107 Brentwood Circle 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married ❑ Married, but separated ❑ Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, MIddle, Last, Su fbc) If wife, give maiden name Rolland Stroh 11. FATHER'S -NAME (First, Middle, Last, Suffix) William- Steffen 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Edna Neubert 13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Rolland Stroh 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial 0 Donation 18a. EMBALMER -SIGNATURE Derek Apfel 18b. LICENSE NO. 1240 16c. DATE (Mo., Day, Yr.) November 10, 2012 ❑ Cremation ❑Entombment o 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 MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 1 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 1e. PART I. Enter the 00 of events -diseases, Injuries, or complicaUons-that directly caused the death. DO NOT enter terminal evens such as cardiac arrest, . APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only dee cause on a Ilne. Add additional lines H necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Ventricular Tachycardia disease or cnndhion resulting onset to death Minutes in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, it b) Ischemic Cardiomyopathy any, trading to the cause Bated line onset to death Years on a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Coronary Artery Disease (disease or Injury that Initiated onset to death Years the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST 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. Hypertension, Hyperlipidemia, Diabetes Mellitus 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE: 0 Not pregnant within past year 0 Pregnant at time of death 21a. MANNER OF DEATH ® Natural ❑ Homicide 0Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑YES ® NO ❑ Net pregnant. but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death o Unknown U pregnant within the past year 0 Sulfide 0 CouW not be determined 0 Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 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? DYES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE B 2:w. DATE OF DEATH (Mo., D. Yr.) November 6, 2012 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH )-23b. -i DATE SIGNED (Mo., Day, Yr.) November 7, 2012 23c. TIME OF DEATH 06:25 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 0 2 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) Jay C. Anderson, 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? 28a. HAS ORGAN OR 0 YES 0 NO 0 PROBABLY ® UNKNOWN 0 YES ISSUE r • El NO ATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED? Not Applicable If 28a 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,8803 28a. REGISTRAR'S SIGNATURE A- 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) November 9, 2012