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<br />SEN THIS..' COPY. CARRIES THE RAISED SEAL OF THE :STATE OF NEBRASKA, iT
<br />CERTIF::.YES 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 />8/26/2019
<br />LINCOLN, NEBRASKA
<br />RUSSELL FOSLER
<br />202207 j.} REGISTRAR O ASSISTANT
<br />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 />Myrna May Roach
<br />2. SEX
<br />Female
<br />3- DATE OF DEATH {iib., Day, Yr)
<br />August 20, 2019
<br />4.CrrY ANDSTATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ker e9B W Nebraska '
<br />1. SOCIAL SECURITY NUMBER
<br />.506,50-9857
<br />5
<br />AGE::'- Last Birthday
<br />effs
<br />Sb: FAEtLiTii NAME (if tlot in ttituton, give street and number)
<br />Prairie Winds
<br />8c. Cl rY OR TOWN OF DEA i H (Include Zip Code(
<br />Doniphan 6.8832:.:
<br />gas RESIOSIIcES7ATE
<br />Nebraska
<br />9d. ST REET"AND`NUM iE .
<br />603 W 6th Street _
<br />9b. COUNTY
<br />Hall
<br />UMDERI. YEAR
<br />Sc. UNDER 1 DAY
<br />MOS..
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />DAYS
<br />9C- CITY OR TOWN::
<br />DOnlpl�n
<br />HOURS
<br />MINS.
<br />S. DATE OF BIRTH it
<br />December 17 "1:839
<br />OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />0 Decedent's Home
<br />El Other (SpecifylASSI
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68832
<br />9g. INSIDE
<br />® YES ❑ NO
<br />1Oa. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Marded* but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (FI
<br />Harold Reach .
<br />Middle, Last, Suffix) If wife, give maiden name;;
<br />Y}L
<br />8
<br />m
<br />roc
<br />22f. LOCATION OF INJURY - STREET >t NUMBER, APT.NO.
<br />11.: FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Edward Aufdenkamp
<br />12 MOTHEIYS NAME (First, Middle, Mal
<br />Emma Harms
<br />me)
<br />j3::EVER H,U.S ARMED.FORCES?
<br />(Yes: Noy or Unk.) t1ID
<br />Give dates of service if Yea.
<br />14a. INFORMANT -NAME
<br />Lisa RObe:Its
<br />14b. RELATIOISHIP TO DECEDENT;.
<br />Daughter ar 'Ma
<br />0 : METHOD OF.DISPOSITION
<br />0 Burial ❑ Donation
<br />El Cremation ❑ Entombment
<br />©removal [ Other Specify)
<br />18a. EMBALMER -SIGNATURE
<br />•Not Embalmed
<br />ICENSE NO.
<br />18c. DATE (Mo..
<br />August 2110319
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />lie. FUNERAL H BE NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Aofet Funetai Home. 1123 W. 2nd. Grand Island, Nebraska
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />1.8:PAit `t Eider ditab sun oI eVeidg- diseases, injuries, or complications -that directly caused the:deatix DO Nt TenMrtonrliiml events such as cardiac arrest,
<br />eapiratafy arrest, or ventrlcolar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only One Cline anal line. Add additional tines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Glioblastoma Multiform Brain Tumor
<br />disease or condition retaking
<br />ugh est ddndtnom N
<br />anY 1e8411ng ttVthlf:y`ahise )ilf+tA .::
<br />n Eno a DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />{disease erldjurytttat hmdated<:..
<br />e"dflta rlteufthii in *49 i;:;;DUE TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />1?1nS1j3dotla:
<br />68801
<br />APPROXitaxitIN ERVAt.
<br />onset to dttli
<br />3 Menthe..;.
<br />onsetia';f9
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />`<Extensive Stroke
<br />20. IFIMALE
<br />•a: Not pegnent Stthin Peet year
<br />0 Pregnant at time of death
<br />. ❑ Nid pregard;.11at pregnant.within 42 days of death
<br />Aid pre nin4 tut pregnant ea days to 1 year before death
<br />OUt knewn x pregnant wahinthe past year
<br />22a. DATE OF INJURY(Mo., Day, Yr.)
<br />22d.:INJURY.ATWORK? ::
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident ❑ Pending investigation
<br />❑ Suicide ❑ Could Oct bedeWMjlned
<br />22b. TIME OF INJURY
<br />2141 IF TRANSPORTATION INJURY
<br />Dnver/Operetor
<br />0 Passenger
<br />❑ Pedestrian
<br />O lir spectiy)
<br />22c. PLACE OF INJURY -At home, farm, street, facto
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />onset to.death
<br />onset
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO:
<br />210. WAS AN AUTOPSY PERFORMED?
<br />YES igNO
<br />21d. WERE AUTOPSY RNDMN(MS AVAILAB
<br />TO COMPLETE CAUSE OF DEATIW
<br />ce building, construction site, etg (Specify)
<br />0
<br />230: DA OEDEATH (Mo., Day, Yr.)
<br />:ZiAtigeslii20.4019
<br />225. DATE SIGNED (Mo., Day, Yr.) 23c. TiME OF DEATH
<br />Auoust.21. 2019 06:05 PM
<br />23d. To the best of my knowledge, death *cowed at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Tai d Fruetilinp, MD
<br />28. DID.TOexcei USE CONTRIBUTE TO THE DEATH?
<br />❑ YES E.NO ❑ PROBABLY 0 UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />240. P
<br />UNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TiME PRONOUN0 DEA
<br />24.. On the bests of esanhnaeen and/or nwernigadun, In try opinion deadt occurred r. .
<br />the time, date and place and due to the eeuse(s) stated. fiiprf ue and TNI.)
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES l NO
<br />2T. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />R)ChBrd FTltehling,::MD, 2116 W Faidiey #400, Box 9802, Grand Island;; Nebra. ska, 68803
<br />REGISTi3AR':S SIGNATURE
<br />28b. WAS CONSENT GRANTED?
<br />•Not Applicable if 28a Is NO
<br />280. DATE FILED BY REtRt71!/tl# {INAy, lila
<br />August 22, 2019
<br />
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