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CERTIFICATION OF VITAL RECORD ND Department of Health and Human Seiviees Bismarck, North Dakota Cetification of Death 2025 02602 THIS IS TO CERTIFY THAT THERE IS ON RECORD IN THE VITAL RECORDS UNIT OF THE DIVISION OF PUBLIC HEALTH, NORTH DAKOTA DEPARTMENT OF HEALTH AND HUMAN SERVICES, BISMARCK ND, THE FOLLOWING ENTRY OF DEATH: NAME: SOCIAL SECURITY NUMBER: PLACE OF DEATH: SURVIVING SPOUSE'S NAME: FATHER'S NAME: MOTHER'S MAIDEN NAME: RESIDENTIAL ADDRESS: PLACE D TH OCCURRED:. FACILITY DR ADDRESS: INFORMANT: INFORMANTS ADDRESS: FINAL DISPOSITION: FUNERAL HOME: MEDICAL CERTIFIER: CERTIFIER'S ADDRESS: IMMEDIATE CAUSE OF DEATH: as a consequence of > as consequence of > as a consequence of-> CONTRIBUTING FACTORS: SUSAN BELLE WILEY 506-92-4174 BISMARCK, NORTH DAKOTA GEORGE SMITH EVERETT CHARLES WILEY- BETTYLOU SCHLEICHARDT 8145 42ND SE WISHEK, NORTH DAKOTA 58495 HOSPITAL INPATIENT SANFORD HEALTH = BISMARCK BISMARCK, NORTH DAKOTA DECEDENT INFORMATION SEX: DATE OF DEATH: MARITAL STATUS: TIME OF DEATH: DATE OF BIRTH: FEMALE DECEMBER 05; 2023 MARRIED 04:23 MARCH 30, 1961 BIRTHPLACE: NEBRASKA / U.S. ARMED FORCES: ' NO FILING DATE: DECEMBER 20, 2023 DATE ISSUED: APRIL 30, 2025 CERTIFICATE NO: 133.23-007226 INFORMANT INFORMATION GEORGE SMITH RELATIONSHIP: 8145 42ND AVE SE, WISHEK, NORTH DAKOTA 58495 DISPOSITION INFORMATION DAKOTA CREMATION SERVICE METHOD: BISMARCK, NORTH DAKOTA FUNERAL EASTGATE'FUNERAL SERVICE PRACTITIONER: BISMARCK, ND 58502 MEDICAL CAUSE OF DEA'TH INFORMATION HAVEN MALISH, j LICENSE NUMBER: SANFORD HEALTH - BISMARCK, BISMARCK, ND 5850? HEMOPHAGOCYTIC LYMPHOHISTIQCYTOSIS HODGKIN'S LYMPHOMA". LICENSE NUMBER: HYPONATREMIA\,SEIZURES, :MALNUTRITIONJ HEPATIC ENCEPHALOPATHY MANNER OF DEATH: NATURAL MEDICAL EXAMINER CONTACTED: NO TOBACCO CONTRIBUTED TO DEATH: NO DATE OF INJURY: PLACE OF INJURY: LOCATION OF INJURY: HOW INJURY OCCURRED: AUTOPSY PERFORMED: NO DECEASED DIABETIC: NO TIME OF INJURY: INJURY AT WORK: TRANSPORTATION INJURY: HUSBAND CREMATION SHANTEL JANGULA 1371 AUTOPSY FINDINGS AVAILABLE: Darin J. Meschke State Registrar of Vital Statistics This certificate is issued in compliance with the laws of the State of North Dakota (NOT VALID without reversed raised impression seal in the Tower fight corner)