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STATS. OF NEBRASKA
<br />WHEN THIS COPY ARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELOW TO
<br />SEA 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 />DArEOP':IlsuAN ,
<br />LINCOLN, NEBRASKA
<br />202403965
<br />SARAH BOHNENKAMP
<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 'DBC♦iDENTS+NAME,(F(rtct, Middle, Last, Suffix)
<br />h1fllrtla Jea:1peding
<br />4 CrntAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand.Island., Nebraska
<br />SOCIAL SECURITY NUMBER
<br />506-30-4265:
<br />6a. AGE - Last Birthday
<br />(Yrs.)
<br />79
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />-8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient'
<br />8b. FAciUTY-NAME (its not Institution, give street and number)
<br />Tiffany.. Square Care Center
<br />CITY OR ypereN OF DEATH (Include Zip Code)
<br />Grand 68803
<br />III. RESIDENCE -STATE '
<br />Nebraska
<br />9d STREET ANC NUMBER
<br />1133 North Howard
<br />8b. COUNTY
<br />Hall
<br />❑ ER/Ou patient
<br />1 DOA
<br />10a MARITAL ST 4TUSATTIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ['Widowed ❑ Divorced 0 Unknown
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo.
<br />June 5, 2019..,.:':'
<br />6. DATE OF BIRTH (Mo.. Dey Yr)'
<br />March 25,1931.:,::
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />6e; APT. NO.
<br />Sf. ZIP CODE
<br />68803
<br />pips Faciliy
<br />40I0ICE 00' L(MIT$>
<br />l YEs ❑. IIor.
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Robert Sperling
<br /># I FAkfER'S NAIVE (First,. Middle, Last, Suffix) 12. MOTHEWS•NAME (First,
<br />Frieda Fuss
<br />Her ry t iebsaekJr
<br />43 EVER IN U S A.RMED••FORCES? Give dates of service if Yea.
<br />(Yes, No, or Unk.) N0
<br />16 ME FHOp OF:PISPOSITION
<br />�' Burial Q Donation.,
<br />Cremation 1J Entombment
<br />Q ri 1;64 [ Othai (spsclly)
<br />14a. INFORMANT -NAME
<br />Robert Sperling
<br />16a. EMBALMER -SIGNATURE
<br />Tracey Dietz
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />a;la Fast.) L lime:NA E AND MAILING ADDRESS (Street, City or Town, State)
<br />Apl l F'Unerat Home; ;1.123 W. 2nd, Grand Island, Nebraska
<br />166. LICENSE NO.
<br />1328
<br />Middle,
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See Instructions and examples)
<br />it. PART 1. Enter the chain of events. diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE Flit$ a) Metastatic Breast Cancer
<br />dossi4or;o."114ibnre
<br />Maiden Surname)
<br />in death). DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, it b)
<br />sin Mycang to the ,310 gyne
<br />ger tine p
<br />i0ii;OUE TO, OR AS A CONSEQUENCE OF:
<br />Enter t4ie UNDERLYINB t AU68 ' C)
<br />the events resulting In death)
<br />LAST
<br />RT.I OTHEI S)GMF
<br />(t iF FEMALE
<br />❑ f of pregnera wlEbl
<br />❑ Pt gnerd at tlree;c
<br />4.1ireipregnent, btu prepluint within 42 days of death
<br />Q Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown N pflgnant vdttda the.past yur
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />ye6':
<br />NT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />TE O(rIN.IURY(lqo, Clay, Yr.)
<br />22d. INJURY AT WORK?
<br />C]TES 0::Na
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicidit
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF IN
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />t)P;INJURY. ;STREETS NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 5, 2010
<br />CITY/TOWNt
<br />2$b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Ji�t)ne; 8 2,01(.: 10:25 PM
<br />2ttd, T-0 iiia` Ut.orm k#a/wtedge, death occurred at the time, date and place
<br />Off** tot#teceese(s) stated. (Signature and Title)
<br />Jana VanWie, MD
<br />2A DID,7(IBACQC UBE CONTRIBUTE TO THE DEATH?
<br />1YES CIPROBABLY 0 UNKNOWN
<br />21h. IP TRANSPORTATION INJURY
<br />❑'_ Ddven(Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />14b. RELATIONSHIra TO DEC)
<br />Husband
<br />16c. DATE (Maar palfty .)
<br />June 9, 26'10
<br />$TATE.
<br />Nebraska
<br />19. WAS MEDICAL EXAMINER
<br />ORCORONERCCM'I GrED?
<br />[1 YES S1 NO
<br />21c. WAS AN AUTOP&T.PERF
<br />❑ YES Q Na
<br />ED?
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES Q NO,
<br />URY-At home, farm, street, factory, office building, construction
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />D.I
<br />toe, On. 1w beds of examination and/or Investigation, M my opinion deathnthiU .
<br />the. One, date and place and due to the cause(s) stated. (Signature and:':t'i )
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ® NO
<br />2T NAME,'I'(TLE AND ADDRESS OP CERTIFIER (Type or Print
<br />Jana VanWi.e, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />arerprot-
<br />26b. WAS CONSENTGRAN'?
<br />Not Applicable if 26a Is NO
<br />28b. DATE FILED BY REGIS
<br />June 10, 2010
<br />Mo., Day,
<br />r.)
<br />
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