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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />`' 10L30/20�3 ,
<br />LINCOLN, NEBRASKA
<br />202305874
<br />SARAH BOHNENKAMP jT
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />aha 1. DEC'EDENT'S -NAME (First, Middle, Last, Suffix)
<br />Faye Marie Graff
<br />CERTIFICATE OF DEATH
<br />4. OMAN') STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Lancaster, Pennsylvania
<br />7..$OCIAL SECURITY:NUMBER
<br />1!94..22-7042
<br />8a. AGE - Last Birthday
<br />(Yrs.)
<br />95
<br />1
<br />I
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Prairie Winds
<br />8c, 911VOR TOWN DEATH (Include Zip Code)
<br />Uon(phan; 68832 r
<br />9a'RESIDENCESTATE
<br />Nebraska
<br />ed. STREET AND NUMBER
<br />603 W. 6th Street
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE• Q{::DE• AT•H ;.
<br />•
<br />HOSPITAL .❑ Ilnpedent
<br />0 ER/Ou patient
<br />0 DOA
<br />111a.MARITAL:STATUSAT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated El Widowed 0 Divorced ❑ Unknown
<br />11.FATHERSNAME (Furst, Middle, Last, Suffix)
<br />William Lester Trimble
<br />13.:EVER.IN U S moo FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />Btalal ❑Donation
<br />Cfematkin) ❑Entombment
<br />Removal ! 0 Other (Specify)
<br />9c. CITY OR TOWN
<br />Doniphan
<br />HOURS
<br />MINS.
<br />2314536
<br />3. DATE OF DEATH;(Mo., Day,` r.)
<br />October 23, 2023
<br />6. DATE OFiBIRTH(Mo., Day,Yr.)
<br />January 20, 1928
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />® Other (Specify)ASSISTED LIVING
<br />(
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68832
<br />9g.INSIDE CflYLIMI 'S
<br />{ YES ❑ N0
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give midden name
<br />Eugene Groff
<br />112. MOTHER'S -NAME (First, Middle,
<br />E Utfl Cramer
<br />14a. INFORMANT -NAME
<br />Neil Groff
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL. HOME. NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All FRiths Funerat Home, 2929 S. Locust Street, Grand Island.' Nebraska for
<br />Other lSoecitYli,
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />Maiden Sumarn
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />16c. DATE (Mo., Day, Yr.),
<br />October 20, 2023
<br />18. PART I. Enter 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 if necessary.
<br />IMMEDIATE CAUSE:
<br />MNIEDIATEcAUSE(P1nai a) acute on chronic hypoxic respiratory faiture
<br />disease Of for tnti0n reeulting
<br />In death}:
<br />Semierdlally list conditions, If
<br />any:ieading to the canes listed
<br />on
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b}acute on chronic diastolic heart failure
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />Entertha UNDERLYING cause c) mitral regurgitation
<br />Idieaad Or Injury that Initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />STATE
<br />Nebraska
<br />171). Zip Code
<br />68801
<br />XIMATE INTERVAL
<br />onset to dot
<br />Days
<br />onset to death
<br />Weeks
<br />onset tit death
<br />Years
<br />1& PARTE. OTHER SIGNIICANTCONDITIONS-Conditions contributing to the death but notresuttln
<br />ulcerative Colitis, hypertension, anxiety, mild cognitive impairment, osteoporosis
<br />(n
<br />the underlying cause given in PART I.
<br />ra5
<br />10. WAS METAL EXAMINER.
<br />OR CORONERCONTACTED?''
<br />❑ YES NO
<br />20. IF FEMALE:.:.
<br />Not pregnant within pant fear
<br />Pregnant et;lme of deaths.
<br />Not pragmru, but pregnant wIthin 42days of death
<br />❑:: Not pregnant, but pregnant 43 days to 1 year before death
<br />El. Unknown if: pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />O Accident 0 Pending investigation
<br />O Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />© Passenger.
<br />© Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED? •
<br />❑'YES NQ
<br />21d. WERE AUTOPSYFINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES ❑ NO.._
<br />22a. DATE OF MIJURY (Mo Day, Yr.)
<br />22d;'I
<br />URY AT WORK?
<br />YES 0 NO '
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc.
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f LOCATION OF INJURY: STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 23, 2023
<br />SPIKY)
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />October 25: 2023 04:25 PM
<br />2.14.Tothe heat of my knowledge, death occurred at the time, date and place
<br />and duo tb the:rause(s) stated. (Signature and Title)
<br />Jav C. Anderson, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIPCODE i':
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />Yoe. On the basis of examination and/or investigation, M my opinion death e4CUnedat
<br />the Inge, date and place and due to the cause(s) stated. (Sign tune thid.. tie)
<br />26a. HAS ORGAN OR TISSUE opRATiont BEEN CONSIDERED?
<br />❑YES ENO
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES i 1 No ❑ PROBABLY 0 UNKNOWN
<br />27 NAME, TITik Ai(D ADDRESS OF CERTIFIER (Type or Print
<br />Jey C. Anderson,MD,729 North Custer Avenue, Grand Islami, Nebraska, 88803
<br />I28a. REGISTRAR'S SIGNATURE
<br />at.riet,A 8 ,?k � .
<br />26b. WAS CONSENT GRANTED?...::.
<br />Not Applicable if 26a Is NO ❑ VES:
<br />D'
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />October 26, 2023
<br />
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