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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 />DATE OF ISSUANCE
<br />202001952
<br />4/29/2019
<br />LINCOLN, NEBRASKA
<br />t resided at the rim
<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 />June Merles Frank
<br />2. SEX
<br />Female
<br />''''' ,11441;S0U' tt,,,,,
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 19, 2019
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Cambridge,. Nebraska
<br />5a. AGE - Last Birthday Sb. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />(Yrs.) MOS. DAYS
<br />95
<br />HOURS MINS.
<br />6. DATE OF BIRTH (MO:, DAV. Yr./
<br />March 27, 1924
<br />7. SOCIAL SECURITY NUMBER
<br />505-24-1211
<br />Sb. FACILITY -NAME (If not tnstitution, give street and number)
<br />Westfield Quality Care
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER ® Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other(Specify)
<br />0 Hospice Facility
<br />8c. CITY OR TOWN OF DEATH (Include Lip Code)
<br />Aurora 68818
<br />8d. COUNTY OF DEATH
<br />Hamilton
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1430 S. Gunbarrel Rd
<br />9e. APT. NO. 19f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />EOa. MARITAL STATUS AT TIME CF DEATH 0 Married ❑ Never Married
<br />❑Married, but separated:; ® Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Fred Krauss
<br />1Ob. NAME OF SPOUSE (First, ; Middle, Last, Suffix) If wife, give maiden name
<br />Marion Frank
<br />12. MOTHER'S -NAME (First, Middle,
<br />Tadie Eschen -
<br />Maiden Surname)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, er Unk.) No
<br />14a. INFORMANT -NAME.
<br />Sandra Huff
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />0 Cremation 0 Entombment
<br />Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />6b. LICENSE NO.
<br />1454
<br />16c. DATE (Mo., Day, Yr.)
<br />April 24, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Greenwood Cemetery
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street. Grand Island. Nebraska
<br />CITY / TOWN
<br />Lexington
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART tante. the chain of events. diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines H necessary.
<br />IMMEDIATE CAUSE:
<br />a) Bradycardia
<br />IMMEDIATECAUSE (Final
<br />di or condition resulting
<br />in death) ,
<br />sequentially lief conditions, if
<br />any, leading to the cause Jilted
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury that initiated
<br />the events resulting m death)
<br />LAST;':
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Failure To Thrive
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Dementia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE IN
<br />onset to death
<br />None
<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 1.
<br />HTN, CKO, Petvis Fracture, Coronary Artery Disease
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE;
<br />0 Not pregnsrd within past year
<br />0 Pregnant at time of death
<br />Not ptegnant„but pregnant within 42 days of death
<br />❑ Net pregnant:but Pragnanf 43 days to 1 year before death
<br />❑
<br />Unknown Hpn3gnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />2d. INJURY AT WORK?
<br />YES ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could; not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />Other/Specify)
<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 b NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />(3a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 19, 2019
<br />A 23b. DATE SIGNED (Mo., Day, Yr.)
<br />ril 22, 2019
<br />I
<br />O ' 3d. TToopthe best of my knowledge, death occurred at the time, date and place
<br />ape C t ;^_ign_rrra and Tafs;
<br />23c. TIME OF DEATH
<br />11:30 PM
<br />IE
<br />g
<br />e »��
<br />W g 24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />date cur) ri•"d t!'s ca: ft:J stated. ftry^rturt tr.; '19r)
<br />. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />► W .:: F 0
<br />o
<br />25, DID TOBACCiS USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES J NO 0 PROBABLY 0 UNKNOWN 0 YES ® NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Jeff Muilenburg, MD, 609 O Street, Aurora, Nebraska, 68818
<br />Jeff Muilenburd, MD •
<br />Exhibit "A"
<br />26b. WAS CONSENT GRANTED? I'
<br />Not Applicable if 28a Is NO 0 YES Ij NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 23, 2019
<br />Ul
<br />(31
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