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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 />10/8/2020
<br />LINCOLN, NEBRASKA
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<br />202.103306
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<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 />Norma Pauline Caulkins
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506-46-1067
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />t ACILITY=N MME (Hnot Institution, give street and rwr..:ier)
<br />3111 Brentwood Blvd
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d, STREET AND NUMBER
<br />3111 Brentwood Blvd
<br />Bb. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed ❑ Divorced 0 Unknown
<br />79
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />2013216
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />October 4, 2020
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />May 24, :1.941
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC
<br />❑ ER/Outpatient ® Decedent's Home
<br />❑ DOA 0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />0 Hospice Facility
<br />99. INSIDE CITY LIMITS
<br />tai YES u NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) H wife, give maiden name
<br />Sterling Gary Caulkins
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Eugene Semm
<br />12 MOTHER'S -NAME (First,
<br />Edna Lockenvitz
<br />Middle, Maiden Surname)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Sterling Caulkins
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />15. METHOD OF DISPOSITION
<br />❑' Burial 0 Donation
<br />rij Cremation ❑ Entombment
<br />❑ Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />October 6, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY / TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17a FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Alt Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events- -diseases, injuries, or complicationaifhat 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 if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Metastatic Lung Cancer
<br />IMMEDIATE cause (final
<br />disease or condition resulting
<br />in death)
<br />Sequentially list conditions, if
<br />any,leeding to the cause listed
<br />on line a,
<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 />17b. Zip Code
<br />68801.
<br />APPROXIMATE INTERVAL
<br />onset tet death
<br />Weeks
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />0)
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<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 ®NO
<br />20. IF. FEMALE:
<br />0 Not pregnant within pat year
<br />0 Pregnant at time Of death
<br />❑- Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 ;Unknown If pregnant within the past year
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. 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❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />2ZF. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN
<br />STATE ZIP' CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 4, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />October 5, 2020 02:50 AM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the eause(s) stated. (Signature and Title)
<br />Travis S. Hageman, MD
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<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. an the basis of examination and/or investigation, in my opinion death OCaurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES l] NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR SSUE s • ATION BEEN CONSIDERED?
<br />❑ YES C7 NO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 26e is NO ❑ YES
<br />❑ NL
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Travis S, Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />October 6, 2020
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