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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARLTIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />A
<br />BCTRUE GORY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />IUMAN-SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORYPOR VITAL. RECORDS
<br />GATE Of ISSUA.1NCE
<br />9'1 /9%2023
<br />LlWCOLN, NEBRASKA
<br />SARAH BOHNENKAM1': r
<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 />.DtrCED>rNTS-NAME .(Frst,; Middle, Last, Suffix)
<br />Mary . Margaret ..Lore
<br />4. an AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday.
<br />(Yrs.)
<br />Nebraska City, Nebraska
<br />7 SOCIAL sECURITYNUMBER
<br />505-82.6920
<br />+s 8b. FACILITY -NAME (if not Institution, give street and number)
<br />412:East ;9th Street
<br />tc.CjTY OR.TCWN OF 4TH (Include Zip Code)
<br />CGrand Island 68901
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />72
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />8a PLACE OEDEATH
<br />HOSPITAL ❑ Inpatient
<br />ER/Outpatlent
<br />❑ DOA.
<br />18 03274
<br />3. DATE OF DEATH (MO, Dai
<br />March 7, 201$
<br />6. DATE OF BIRTH (Mo., Day, Yrj'
<br />June 5, 1945
<br />OTHER ❑ Nursing Home/LTC ❑ (i
<br />E Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />ty
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />ext;STREETAND NUMB6tt::
<br />412 East 9th Street
<br />10a,?MARtTALSTATUS.AT TIME OF DEATH 0 Married 0 Never Married
<br />❑ Married, but separated E Widowed 0 Divorced 0 Unknown
<br />11 Ff►THI:R'S-AIAME t!ifst, Middle, Last, Suffix)
<br />Earl - Clevertofr' Wiles
<br />13. EVER iN U:E ,ARMED FORCES?
<br />(Year No, or
<br />1S. METHOD OF DI8POSI71'N
<br />❑ Butfaii.
<br />❑Donatott
<br />Crematlot ❑ Entombment
<br />❑?RetnovaF ❑ ONS (Specify)
<br />Vie. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />4INSIPE CITYLIMITS
<br />1 YEs ❑ Nci
<br />1:01i NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden
<br />William Lore
<br />Give dates of service If Yes.
<br />14a. INFORMANT -NAME
<br />Mitch Dubbs
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12. MOTHER's.NAME (First, Middle , Maiden Surname)
<br />Mary Everett
<br />16d: CEMETERY, CREMATORY OR OTHER LOCATION
<br />•
<br />Central Nebraska Cremation Services
<br />17a.FUNERAL..HOME NAME AND MA LING ADDRESS (Street, City or Town, &tate).;
<br />a4t?fel I^unt3lat 1•lolne. 1123 W. 2nd, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />14b. ReeiknoN$WP TobecedENT
<br />Son
<br />16c. DATE (Ma, Day;,
<br />March 8.2018.:
<br />MATE
<br />Nebraska
<br />17b. Zip Coda
<br />88601'
<br />CAUSE OF DEATH (See! instructions
<br />I'd examples)
<br />18. PART 1. Enter the chain of events- -diseases, Injuries, or comp) caaonsdhat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventrieuler fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional liras If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Cardiac Arrest
<br />In death)
<br />Sequentially IIst conditions. If.
<br />any, leading to the caus.Sstod.
<br />E/IleKitt4 tAvotooxiNe CAuse
<br />(disease or InJui .that initlaterl.
<br />the events resulting M death)
<br />LAST
<br />18.;PARTIi.:OTHER
<br />Respiratory Artss
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Colon Cancer
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR -ASA CONSEQUENCE OF:
<br />d)
<br />IF1CANT CONDITIONS -Conditions contributing to the; death but n
<br />20 IFFEMALE; ...
<br />Not p1egnem:Wteltn�pa ryear
<br />('replukn td wipe of daa f,,
<br />❑ Nat pregnit but pntgnaht within 42 days of death
<br />fl Notpregnant, but pregnant48 days to1 year beforedath
<br />-Unknown if pregnantw16 n the past year
<br />a 22tCOATE OF IM jURY (M0. Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ;❑ NO ,
<br />suiting'
<br />nderlying cause, given In PART I.
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide ...
<br />0 Accident ❑ Pending Investigation
<br />❑
<br />Suic de 0 Could not be determined
<br />22b. TIME OF INJURY
<br />216. IF TRANSPORTATION
<br />0 0rte rlOperator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />INJURY
<br />onset to dearth
<br />oneetl
<br />onset to death
<br />19. WAS MEDICAL#EXAr6INERi
<br />. OR CORONERCONTACTED?
<br />❑ YES ENO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES Oa NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES El NO
<br />22c. PLACE OF INJURY -At home, fart, street, factory, office building, constructlott site, Ma (Specify)'
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />LOCATION OF (JURY- STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 7, 2018
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />CITY/70WN'
<br />March $ 2018 12:28 PM
<br />TOUR, kiwi of 1„y knowledge, death occurred at the time, date and place
<br />end Rota thit causes) stated. (Signature and Title)
<br />Dron Gauchan, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEAfit"
<br />P. ODE:.
<br />24d. TIME PRONOUNCED DEAD
<br />24s.en the bibile of examination and/or investigation, In my opinion debcSu
<br />t orred at
<br />dee tkne'date and place and due to the cause(*) stated. (Signature andThIe)
<br />26. DI.D TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN:. OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES 121 NO ❑ PROBABLY 0 UNKNOWN 0 YES NO
<br />27 I AM , f1T °AND ADi itESS OF CERTIFIER (Ty
<br />Fpe or Print)
<br />Ion Gauchan, Mb, 2621 W Faidley Avenue, Grand Island, Nebraska, 68803
<br />28a REGISTRAR 8 SIGNATURE I/5greaa-
<br />�%
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO . ,❑YES ❑ N
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 13, 2018
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