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<br />WHEN THIS I'' 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 />DATE OFISSUANCE
<br />12/12!2018
<br />LINCOLN, NEBRASKA
<br />lc
<br />2020010 io
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE' OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Joyce Stubbs
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ravenna, Nebraska
<br />5a. AGE Last Birthday
<br />83
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOB.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November 14, 2018
<br />6. DATE OF BIRTH (Mo, Day, Yr.)
<br />August 5, 1935
<br />7. SOCIAL SECURITY NUMBER
<br />508-38-1316
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />3130 W 15th St
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />0 Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Max Veit
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Keith Stubbs
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Bess Adam
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or unk.) No
<br />15. METHOD OF DISPOSITION
<br />❑Burial 0 Donation
<br />® Creme:ion 0 Entombment
<br />❑ Removal 0 Other(Specify)
<br />14a. INFORMANT -NAME
<br />Keith Stubbs
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo„ Day, Yr.)
<br />November 19, 2018
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Crematory
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Livinaston-Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska
<br />CITY / TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17b.Zfp Code
<br />68803
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART I. Enter the Chain of ev$ms-diseases, Injuries, or eompllcationsdhat directly caused the death. DO NOT enter. terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular Bbrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one Cause ext a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Respiratory Failure Secondary To COPD And Heart Failure
<br />disease or condition resulting
<br />in death)
<br />Sequentially list condition, it
<br />any, Wading to the cause listed:
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury -that Initiated;.
<br />the events resulting in death) -:
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<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 />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but stagnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />2d. INJURY AT WORK?
<br />0 YES ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident ❑ Pending investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other.(SPecifY)
<br />INJURY
<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, fans, 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 />November 1.4, 2018
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />November 28, 2018 10:58 PM
<br />23d. To the Cwt of my knowledge, death occurred a: the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Shoal) Z. Jurieio, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES El NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR SSUE • e
<br />❑ YES El NO
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<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 cause(s) stated. (Signature and Title)
<br />ATION BEEN CONSIDERED?
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Shoaib Z. June)o, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑ YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (Mo,':Day, Yr.)
<br />December 3, 2018
<br />
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