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<br />j%�rrr,,�,r,t,STATE OF NEBRASKA
<br />fu19111yAi �rrcri,eq
<br />WiIEN THIS :, COPY CARRIES THE RAISED 'SEAL F < l>tf . :ATE: OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUECOPY' OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECOR©S,OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />::DATE OF:ISSVANCE
<br />4/5/2018
<br />LINGO .rel, NEBRASKA
<br />STANLEY . COOPER
<br />202400434 ADEPAR.
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OFHEj11kT#i=AND::.HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Diana Louise Chism
<br />ATE OR').....RITORY, OR FOREIGN COUNTRY OF BIRTH
<br />St.`Fain, ! e.braaka
<br />7. SOCIAL SECURITY NUMBER
<br />506=58-8436. .
<br />FACItiTY NAME (if notI.nstitution, give street and number)
<br />Tiffany Square:;Care Center
<br />CITY OR TOWN OF DEATH (Include Zlp Coda)
<br />Grand Island 68803
<br />9a, RESIDENCESTATE
<br />tbraska.:::: .._.._ _.;
<br />9b. COUNTY
<br />Hall
<br />Sa.AGE Lest: Birthday'
<br />(Yrs.)
<br />Six UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MaS..
<br />:DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL [] inpatient
<br />Q ER/OutPatlent
<br />9c CITY Ott TOwN
<br />Grand:Talar d
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATir (Mo.,
<br />February 1, 2014
<br />6. DATE OF BI!(TH (Ileitis,
<br />November20..1946 .
<br />OTHER ® Nursing Home/LTC
<br />[] Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />E
<br />Id. STREET AND NUMBER
<br />1136 N. Howard
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />Yr.)
<br />I ospice Facility
<br />90,'#NSIDE erritomno
<br />® YES ONO
<br />10*.43ARITAL STATUS..AT,TIME OF DEATH ® Married 0 Never Married
<br />( :Married, but
<br />000.0 .0 0 Widowed 0 Divorced 0 Unknown
<br />11 FATHER' NAME (first, Middle, Last, Suffix)
<br />Robert Roy
<br />13. EVER IN Uitt::ARMEP.:FORCES? Give dates of service if Yes.
<br />(yea
<br />15 'METHOD OF OISPOSiTION
<br />®`Burial '[]Donation
<br />O Cremation 0 Entombment
<br />O;Rertlovai 0 DIher,:(Specif)
<br />tOb; NAME,Df SPOUSE (Fait,;.:, Middle, Last, Suffix) if wife, give maiden flirts
<br />Gary Ch(Sm
<br />1Z. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Beulah Keldsen
<br />14a. INFORMANT -NAME..
<br />Gary C(lism .
<br />16a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />16b. LICENSE NO.
<br />1092
<br />14b. RELATIONSHIP, TO REcE NT.;
<br />Spouse •
<br />tic. DATE (Mo., oaY,Yrk
<br />February 5, 2014
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />17e FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel, 3005 S. Locust St.. Grand Island. Nebraska
<br />CITY / TOWN
<br />Grand island
<br />CAUSE OF DEATH (See instruptions and examples)
<br />Is PARti Entact}n:ohale rents--diseases,injuries, or complications -that directly causadtha:death DONOTst: ntanSMAteWntssuch ascardiac inset,
<br />. teapiretory epic$ at ventricular fibrillation without showing the etiology DO NOT AI18REVIATE, Spier omit one Cause en s Ilse. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Respiratory Failure
<br />IMMEDIATE CAUSE (Final
<br />disease Or condition reediting
<br />3n death)
<br />Sequenually het co iditldns, If
<br />any'.;leeding'to tfie.RaUIl*:.11U54
<br />on linea
<br />Enter the UNDERLYING CAUSE
<br />td,aUIse orinjuty:that inINatad
<br />the events reaching m dastftj
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) End Stage Chronic Obstructive PulmonaryDisease
<br />ria :zrp coils;,
<br />APPROXIMATE IISi'E 1
<br />onset Lodi tit
<br />Days •
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />20.10*E4AI-00
<br />® Not pregniMViithM past year
<br />0 Pregnant at time of death
<br />ID$Til pregnant .but piregna.M within 42 days of death
<br />•Not pntgnantbuf tat3griait 43 days to 1 year before death
<br />Unknown if ptegnant yAtliin the past year
<br />DATE OF INJURY (Mo., Day, Yr.)
<br />INJURY AT;WORK?
<br />21a. MANNER OF SEATH
<br />Natural 0 ttahticide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 coukt tot be detonrifined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At ho
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />LOCATION OF INJURY • STREET & NUMBER, APT.NO.
<br />2.Ib IF1RANSPORTATION
<br />'Driver/Operstor
<br />0 Passenger
<br />Pedestrian
<br />04.1. (specify)
<br />INJURY
<br />farm, street,
<br />CITY/TOWN
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONERCONTACTEO?
<br />NO :.:.
<br />21c. WAS AN AUTOPSY PERFORMED'
<br />❑YES alNO
<br />21d. WERE AUTOPSY 014pplGS.AVAILAtm
<br />TO COMPLETE; CAUSE. OF; DEATH?
<br />D YES 010.404i.''
<br />tory, office building, construction site, etc. ('
<br />STATE
<br />23ttt DATE of.6eATM (Mo., Day, Yr.)
<br />Fettra 9 € 2014
<br />b.,( .r..,`s„Pwtut/ED (Mc., Day, Yr.) 23c. TIME OF DEATH
<br />February 10, 2014 03:20 PM
<br />d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the ause(s} stated. (Signature and Title)
<br />t# Settle MD
<br />2&:DI0TOBACCO tiSE(ttiNTRIBUTE TO THE DEATH?
<br />(A YES .D NO ❑ PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Gary ,Sett*s, MD, 2116 W Faidley #400, Box 9802, Grand Isla;
<br />:24a< tO ATE SIGNED (Mo., Day, Yr.)
<br />'2.40:PRONOUNCED NOUNCED DEAD (Mo., Day, Yr.)t
<br />ify)
<br />24b. TIME OF DEATK
<br />24e. On die basis of examination and/or Investigation, In my Ophnton
<br />the time, date and place and due to the cause(s) stated.4Sig/umrre
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ig] NO
<br />20a REGISTRAR'S SIGNATURE
<br />d, Ne:traska, 68803...
<br />26b. WAS CONSENT GRAN
<br />Not Applicable If 26a Is NO
<br />at.
<br />28b. DATE FILED BY REGISTRAR: (Mo
<br />February 10, 2014
<br />Yi
<br />
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