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<br />STATE OF NEBRASKA
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<br />WHEN TH.IS COOT' 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 11E NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />11111111.
<br />6
<br />A
<br />I
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<br />DATEO#SSUAN;
<br />41 /1512023 °'
<br />LINCOLN, NEBRASKA
<br />202306323
<br />SARAH BOII)ENKAMP' T'
<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 DECSDENT'S*NAME (First, Middle, Last, Suffix)
<br />Marie{
<br />011014 1'P.401
<br />4. CITY:AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Denver, Colorado
<br />y40 NUMBER
<br />505,38 7426_
<br />6b. FACI4#TM•NAME (ff not:tnstitution, give street and number)
<br />Wedgewood Care Center
<br />80. CITY OR TOWN OF DE1t'f'#I (Include Zip Code)
<br />Grand Islalltl .68803<:
<br />9a. RESIDENCE•STATE ,:
<br />Nebraska
<br />90,: STREET: ANQI:iem TER :
<br />150 4 Churel )toad
<br />9b. COUNTY
<br />Hall
<br />5a. APE: Last Birthday
<br />(Yrs.)
<br />76
<br />SbUNDERIYEAR
<br />2. SEX
<br />Female
<br />12 02630
<br />5c. UNDER 1 DAY
<br />MOS. DAYS
<br />6a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />1011 MARITAL STATUS ATTIME OF DEATH E Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />14. FATHERS -NAME (First, Middle, Last, Suffix)
<br />Ellery Hooper
<br />13 EVER IN U S ,ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />❑ Bute/ . ❑ Dfmat}al
<br />E Cremation [ Entombment
<br />❑. Removal ❑ Othef (Specify) ,
<br />9c. CITY OR TOWN
<br />Grand Island
<br />101s, NAME OF SPOUSE (First,
<br />Morris Pool
<br />14a. INFORMANT -NA
<br />Morris Pool
<br />16e. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />HOURS
<br />MINS.
<br />3. DATE OF DEAT'
<br />July 23, 201
<br />6. DATE OF BIRTH MO., Day, Yr.)
<br />May 1, 1936.:..
<br />OTHER E Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />Middle, Las(, ' Suffix) If wife, give maiden it
<br />9f. ZIP CODE
<br />68801
<br />11, 913180 Feat*
<br />12. MOTHERS -NAME (First, Middle, Maiden Surname)
<br />%Pit;Kruse;
<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 />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />9g.1NSIOE'CITN LIMITS
<br />i .YES ❑ N£;;
<br />14b. RELATIONSHIP; TO DECIEDI
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />July 23, 2012
<br />Pt) ns and examples)
<br />18. PART I. Enter thephalli of events- {diseases. injuries, or complications -that directlycaused 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 one line. Add additional lines H necessary.
<br />CAUSE OF DEATH(See Instru
<br />IMMEDIATE CAUSE:
<br />IMMGDIATECAUSEWtnat a) Lung Cancer With Malignant Pleurat Effusion
<br />dlsetse or condition asu6&ig •
<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 />e)
<br />Emerthe UNDERLY !1B CAUSE
<br />idlin iss of Ming thin inkieted
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST'.. d)
<br />It PART II OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resuitlng In the underlying cause given in PART I.
<br />AnXIBty
<br />STATE'
<br />Nebraska
<br />in), Zip Code
<br />68801
<br />T
<br />APPROXIMATE INTERVAL
<br />onset to rpt ..
<br />Three Weeks:
<br />19. WAS MEDICAL -EXAMINER
<br />OR CORONERCtiNTACTED?'
<br />❑YES': ENO
<br />20 IF FEMALE:
<br />© NCl pregtiantMwit in paZt y:a r
<br />❑ Prhgnam#tttnieafdeath
<br />NOS pl8$itant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant43 days to t year before death
<br />▪ Unknown if pregnant within the past year
<br />2211. DATE OF INJURY (lino.; Day, Yr.)
<br />22d, INJURY AT WORK?
<br />OYES ❑ No
<br />21a. MANNER OF TH
<br />E Natural ❑ Homlcid9
<br />❑ Accident 0 PendingInveafigation
<br />suicide ❑ CourDEAd nos be detennhied
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />.❑
<br />Driver/Operator
<br />❑;.Passenger
<br />❑'Pedestrian
<br />0
<br />Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ENO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?`
<br />❑ vas ❑ No
<br />22c. PLACE OF INJURY -At home, fair, street, factory, office building, construction site, etC.(8 4Ny)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY. STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />July 23; 2012
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />JuIv .23 .2012
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />01:00 AM
<br />234 Til theitest lir my knowledge, death occurred at the time, date and place
<br />find due to the cadse(s) stated. (Signature and Title)
<br />Jane A:MCDonald, MD'!
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />SEES NO •❑;PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZLPCODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />240.On dor bagt9 of examination and/or Investigation, M my opinion death qdphfren
<br />the time, date and place and due to the cause(s) stated. (Signature and Tidaj
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES ENO
<br />, NAME, TITLE Alb Al DI SSS OF CERTIFIER (Type or Print
<br />Jane/V. l'teDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE AI IhQ��ti�,��
<br />\JV/
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES rj NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />July 24, 2012
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