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<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 />LINCOLN, NEBRASKA
<br />2 0 2 0 0 0 5 0 0 ASSISTANT STATE REGISTRAR
<br />RUSSELL FOSLER
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATEOF DEATH
<br />1. DECEDENT'S -NAME first, Middle, Last, Suffix)
<br />Eileen Marie Samway
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand island, Nebraska
<br />t. 7. SOCIAL SECURITY NUMBER
<br />a
<br />c 508-58-9642
<br />lib. FACILITY -NAME (0 not Institution, give street and number)
<br />420 6th Ave.
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />St. Libory 68872
<br />9e. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />420 6th Ave.
<br />9b. COUNTY
<br />Howard
<br />Sa AGE- Last Birthday
<br />75
<br />b. UNDER 1 YEAR
<br />MOS. DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />0 ER/Outpatient
<br />LJ - ate►
<br />9c. CITY OR TOWN
<br />St. Libory
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />3. DATE OF DEATH(Mo., Day, Yr.)
<br />September 15, 2019
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />April 21, 1944
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />_ j'Other (Spr.Hy)
<br />8d. COUNTY OF DEATH
<br />Howard
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68872
<br />0 Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />❑ YES ®NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />❑;Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Guy Jay Godown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />James Samwav
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Mary Agnes McCarthy
<br />13. EVER IN U.S, ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Utak.) No
<br />15. METHOD OF DISPOSITION
<br />Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />❑gRemoval 0 Other (Specify)
<br />14a. INFORMANT -NAME
<br />Larry Kosmicki
<br />14b. RELATIONSHIP TO DECEDENT
<br />Significant Other
<br />16a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />16b. LICENSE NO.
<br />1397
<br />16c. DATE (Mo., Day, Yr.)
<br />September 20, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />17a.>PUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island, Nebraska
<br />CITY / TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />176 ZIp Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART L Enter the chain af events- -diseases, blur's', or complications -hat directly caused the death. 00 NOT enter terminal events such es cardiac arrest,
<br />iesphatory arrest, or ventricular fibrillation without slowing the etiology. DO NOT ABBREVIATE. Enter only one cause en a ane. Add additional lines if necessity.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Respiratory Failure
<br />disease or condition resulting -
<br />bt death)
<br />Sequentially d.t conditions, l
<br />any, leaning to the cause listedi
<br />on line a
<br />Enter the UNDERLYING CAUSE
<br />(diseeee er Inlury�thet hiIU e4
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Smell Cell Lung CB'Cinorna With PAttastasie
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Hyponatremia
<br />Poorly Differentiated Neuro:ndocr ne Ttirnnr
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)Syndrome Of Inappropriate Antidiuretic Hormone Secondary To Small CeII Lung
<br />Carcinoma/Paraneoplastic Syndrome
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Hypertension, Chronic Obstructive Pulmonary Disease, Osteoporosis, Underweight, History Of Tobacco Use
<br />20. JF_IFEMALE:
<br />®` Not pregnant Within peat year
<br />t1 ❑ Pregnant at time of death
<br />❑ Not pregnant,: but pregnant wlthin 42 days of death
<br />❑ Not prehpwnt,: but peagnant43 days to 1 year before death
<br />❑ Unknown IfPregnant waada dte Wet year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT:WORK?
<br />YES ONO
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY'
<br />0 Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />0 Other(Specify)
<br />APPROXIMATE INTERVAL
<br />onset to heath
<br />24 Hours
<br />Onset to death
<br />9 Moritl:s
<br />onset to death
<br />5 Days
<br />onset to death
<br />6 Months
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®No
<br />21c. WAS AN AUTOPSY PERFORMED?.
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify).
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />eptemDer:15, ZVI9
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH.
<br />u 1 September 30.2019 10:55 AM - "
<br />O Sol. To the best o/ my knowledge, death occurred at the titre, data and place
<br />and due to the eauea(s) slated. (Signature and TNN)
<br />Mathew Day: MD
<br />CITY/TOWN
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES 0 NO 0 PROBABLY 0 UNKNOWN
<br />ZJZ
<br />O
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<br />ti
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />tic. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, In my opinion death occurred M
<br />the time, date and place and due to the causes) stated. (Signature and Tills)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES IINO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO Q YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Mathew Da?y, MO 729 N Custer Ave, Grand Island, Nebraska, 68803,
<br />28a REGISTRAR'S SIGNATURE .A"
<br />28b. DATE FILED BY REGISTRAR( Day, Yr.)
<br />September 30, 2019
<br />CD
<br />01:
<br />O
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