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Va r.I I.Iui VI%P'a { '"°�frdAMA9Avt x Ora yiax• :aki54riWMNPas axfii4iflit' it , trrYii4W,4a�� 4rah1SW)f1� f''iwi.on 1dd l/ts• ._ �'+.:_-Au... -. ... tit e..€.ra -.- a4 e iv... -,., ,«<i%.�i`.>.: , . .,:51:...x,_ ...:ms's. r.-- WHEN THIS _" COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 9/29/2020 LINCOLN, NEBRASKA 202008523 7 a6d 1 ,/d ft.4i7..Ct•m SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 20 12561 Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death. I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Sharon Ann Moeller 2. SEX Female 3. DATE OF DEATH (Mo., pay, Yr) September 21, 2020 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 6b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Grand Island, Nebraska (Yrs.) 73 MOS. DAYS HOURS MINS. September 14, 1947 7. SOCIAL SECURITY NUMBER 506-58-7692 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility' 8b. FACILITY -NAME (If not Institution, give street and number) 2750 E. Chapman Rd 0 ERlOutpatient ® Decedent's Home 0 DOA 0 Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2750 E. Chapman Rd Be. APT. NO. 9f. ZIP CODE 68801 90. INSIDE CITY LIMITS ❑ YES fg NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married ❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Arthur Eugene Moeller 11. FATHER'S -NAME (First, Middle, Last, Suffix) Arthur Roberts 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Lulu Castor 13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Arthur Eugene Moeller 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION 0i3nrisl ❑Donation 16a. EMBALMER -SIGNATURE Stacie L Cook 16b. LICENSE NO. 1495 16c. DATE (Mo., Day, Yr.) September 24, 2020 ❑ Cremation ❑ Entombment ❑ Removal ' 0 Other (Specify) 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Wiegert Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events- -d , Injuries, or complications.hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE cAUEE (proal a) Lung Cancer disease or eenditiorl re6uhing onset to death Months m death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, it b) any, leading to the cause listed Eine onset to death - on a DUE TO, OR ASA CONSEQUENCE OF: Enter; the UNDERLYING CAUSE c) (disease Or injury that initiated onset to death the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART IR. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Hypertension; CVA 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED'? ❑ YES ® NO 20. IF FEMALE: ❑ Not pregnant within past year 0 pregnant at time of death ' 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO ❑ Not pregnant, but pregnant within 42 days of deathSuicide ❑ Not pregnant, but pregnant 43 days to 1 year before death ®unknown if pregnant within the past year ❑ ❑ could not be determined 0 Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY F(NDINGB AVIULAB E TO COMPLETE CAUSE OF DEATH? 0 YES ❑ NO 225. 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? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY I' STREET & NUMBER, APT.NO. CITY/TOWN STATE MP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) September21, 2020 To be completed by I CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) September 21, 2020 23c. TIME OF DEATH 04:34 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 254. To the beet of nip knowledge, death occurred at the time, date and place and due to the sausels) stated. (Signature and Title) Chad Vieth, MD 24e. On the basis of eseminatlon and/or Investigation, In my opinion death °Centredat the time, date and place and due to the cause(s) stated. (signature and TRIM) l: 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES RI NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR SSUE r • ATION BEEN CONSIDERED? 0 YES i a NO 26b. WAS CONSENT GRANTED? .. Not Applicable If 26a is NO DYES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE28b. ��?' "z1.-. DATE FILED BY REGISTRAR (Mo., Day, Yr.) September 22, 2020 Exhibit "A"