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<br />WHEN .. MIS 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 A2
<br />DATE OF ISSUANCE
<br />1/24/2020
<br />LINCOLN, NEBRASKA
<br />202001374
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OP HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Donna Rojene Harders
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 13, 2019
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Arcadia, Nebraska"
<br />7. SOCIAL SECURITY NUMBER
<br />505-36-3632
<br />8b.
<br />6a. AGE - Last, Birthday
<br />(Yrs.)
<br />84
<br />FACILITY -NAME Of not Insdtudon, give street and number)
<br />Good Samaritan Society -Grand Island Village
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />1124 S Burwick
<br />9b. COUNTY
<br />Hall
<br />Sb. SUNDER 1 YEAR
<br />6c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />September 9. 1935
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER E Nursing Home/LTC
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />10a. MARITAL AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Chancy L Smith
<br />13. EVER. IN u.s. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />16.:METHOD OF DISPOSITION
<br />In Burial 0 Donation
<br />❑ Cremation 0 Entorhbment
<br />[3 Removal ; 0 Other (Specify)
<br />9c. CnY OR TOWN
<br />Wood River
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />0 Hospice Facility
<br />9g. INSIDE CITY` LIMITS
<br />® YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) H wife, give maiden name
<br />Doyle Harders
<br />I12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Roene S Prettyman
<br />14a. INFORMANT -NAME
<br />Craig Harders
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCoy
<br />b. LICENSE NO.
<br />1191
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />16c. DATE (Mo., Day, Yr.)
<br />December 18, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Cemetery
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17a FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home. 1123 W. 2nd, Grand Island, Nebraska
<br />1710. Zip Code
<br />68801
<br />CAUSE OF DEATH (See Instructionsandexamples)
<br />16. PANT I, Eatetthe chaln of -Cants- -diseases, Injuries, or complications -that directly Salsa the death. DO NOT enter terminal events such as cardiac arrest,
<br />respw4tory arrest, erventticular fibrillation without showing the etiology. DO NOT ABBREVIATE.Enter only one cause On 4 8n*. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Fina a) Metastatic Cancer Of Pancreas
<br />disease or condition resulting
<br />In death)
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />SegueMielhr list conditions, if b)
<br />anyleadaa to the ave* riled
<br />on Zine a.
<br />Enter the UNDERLYING CAUSE
<br />(dlseeae er Iniurylhat lnitieted
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />the events "tenting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />3 Years
<br />onset to death
<br />onset to -death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES E NO
<br />20. IF FEMALE:
<br />❑ Not pregnant whhln past year
<br />❑ Pregnant at time of death
<br />❑.
<br />['No
<br />piedmont, but pregn4nt within 42 days of death
<br />piegnMld:, bid pregnant 43 days to 1 year before death
<br />❑. Unkrwwo k Megf*rd within thepast year
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION
<br />❑Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />INJURY
<br />21c. WAS AN AUTOPSY PERF
<br />❑ YES E NO
<br />21d. WERE AUTOPSY FINDINGSAVAILABLE
<br />TO COMPLETE CAUSE OF DEATH/
<br />ID YES 0 N
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />2.20, INJURY AT WORK?
<br />OYES ONO
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specly)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 13, 2019
<br />CITY/TOWN
<br />), 23b. DATE SIGNED (Mo., Day, Yr.) 23e. TIME OF DEATH
<br />8 JJ December 23. 2019 08:00 AM
<br />w 23d. To the best of my knowledge, death oceurmd at the tiros, date and place
<br />a and sew to the cause(*) sand. (Signature and Tide)
<br />l'' GarySettie,;MD
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES In NO 0 PROBABLY 0 UNKNOWN
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD....................
<br />24e. On the basis of examination and/or Investigation, In my opinion death occurred at
<br />the time, date and place and due to the ausa(s) sated. (Signature and Tale)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />27. NAME, TITLE ANO ADDRESS OF CERTIFIER (Type or Print
<br />Gary Bettie, MO, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br /><REGISTRAR `S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO 0 YES ❑ NO
<br />28b. DATE FILED BY REGISTRAR (Mo Day, Yr.)
<br />December 23, 2019
<br />
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