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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 />12/10/2020
<br />LINCOLN, NEBRASKA
<br />202103212
<br />4'Uf?. 4.i
<br />SARAH BOHNENKAMP
<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 />Margaret Ann Harders
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />McCook, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505.98.9253
<br />6a. AGE - Last Birthday
<br />(Yrs.)
<br />56
<br />8b FACILITY -NAME (If not Institution, give street and number)
<br />1509 Meadow Road
<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 />'(509 Meadow Road
<br />9b. COUNTY
<br />Hall
<br />IDa, MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5e. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />20 17387
<br />3. DATE OF DEATH (Mo., Day,Yr.)
<br />Decembet 2, 2020
<br />6. DATE OF BIRTH (Mo. Day, Yr.)
<br />June 22, .1964
<br />OTHER ❑ Nursing Home/LTC
<br />® Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />MI YES D. NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name``
<br />Dale Harders
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First,
<br />Verle K Knepper Cecilia Otter
<br />Middle, Maiden Surname)
<br />13, EVER IN U.S. ARMED FORCES? Give dates of service K Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Dale Harders
<br />14b. RELATIONSHIP TO DECEDENT
<br />SPOUse
<br />15. METHOD OF DISPOSITION
<br />Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />❑`Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCoy
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />1191
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART I. Enter the chain of events- -diseases, Injuries, or complications4het directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory west, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Colon Cancer Metastatic
<br />IMMEDIATE CAUSE (Final
<br />disease or condittort resulting'
<br />In death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading to the cause listed
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that itlalated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<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 />Net pregnant within past. year
<br />0 Pregnant et lime of death
<br />0 Hot pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑.:,Unknown if pregnant within the pest year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 DriverlOperetor
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />16c. DATE (Mo., Day, Yr.)
<br />December 7, 2020
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />2 Years
<br />onset to death
<br />ons
<br />onset to death
<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 FINDINGSAVAILAIN.E
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22s. DATE OF INJURY (Ma., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES ONO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />2?f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />a.
<br />u 0
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 2, 2020
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 6, 2020
<br />23e. TIME OF DEATH
<br />03:00 AM
<br />214. To the bast of my knowledge, death occuedn at the time, date and place
<br />,no
<br />due to the causes) stated. (Signature and Tkle)
<br />Ryan Ramaekers, MD
<br />u
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />240. On the basis of examination and/or Investigation, In my opinion death occurred et
<br />the time, date and place and due to the causes) stated. (Signature Ant Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES IE NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ❑ NO
<br />tab. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO < ❑ YES(
<br />0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan Ramaekers, MD, 2116 W. Faidley Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />ami .n2in=.-
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />December 8, 2020
<br />
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