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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AI~D,I iU(~4~1/ SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA5~4-t1EPAR)1M~~1~ O rF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR l~f'AL;>(~CO. 1,Y$.' .. t :
<br />DATE OF ISSUANCE ~ 1 ~- r ~ t
<br />09/08/2010 S~A~ILEY S. Co2'~PER :. --
<br />z o i o o~ i o i ~ ~rINE~~~ ~L~~ :~,
<br />LINCOLN, NEBRASKA F~/M74'~11:SERW1'CES~ ""• ~ « '"
<br />r.. ,
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVfdC~$ ' • ~'~^~' l •~ ~ ~ `:, +'; • H µ' , ~ Q 02482
<br />CERTIFICATE OF DEATH ~F ~~S •'••~.-..---' °"
<br /> 1. DECEDENT'S-NAME (First, Mlddla, Last, Suffix) 2. SEX
<br />• 8yDATF QF-D 7w (Mo., Day, Yr.)
<br /> Phyllis Grace Sober Female
<br />`'. Sept~n8~r 3, 2010
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN GDUNTRY OF BIRTH ba. AGE • Last Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY e, OgTE OF BIRTH (Mo., Day, Yr.)
<br /> lYro•1 MOS. DAYS HOURS MINE.
<br /> Yuma, Colorado 87 November 24, 9922
<br /> 7. SOCIAL SECURrrY NUMBER 8a. PLACE OF DEATH
<br /> 508-14-7205 HOSPITAL ®Inpatlant OTHER ^ Nursing Hgma/LTC ^ Hoapica Facility
<br /> 8b. FACILITY-NAME (If not Institution, glue street and number) ^ ER/Outpatlant ^ Decedent's Noma
<br /> Good Samaritan Health Systems ©DoA ^ other (specity)
<br />~ Bc. CITY OR TOWN OF DEATH pnclude Zip Code) ed. GOUNTY OF DEATH
<br />o Kearney 68948 Buffalo
<br /> sa. RBSIDENCESTATE 9b. COUNTY 8c. CITY OR TOWN
<br />z Nebraska Adams Kenesaw
<br />~ 9d. STREET AND NUMBER a. APT. NO. 9F. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> 15224 5. 190th Road 68956 ^ YES ®No
<br />~ 10a. MARITAL STATUS AT TIME OF DEATH ^ Married [] Never Married /0b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, glue maiden Hams
<br />!E
<br />m` ^ Marrlad, but separated ®Wldowed ^ Divorced ^ Unknown Cornell Sober
<br />~ 71. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br /> Horace Perry Jessie Grothe
<br />O'
<br />(= 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. f 4a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ (Yea, No, or Unk.) No Judy Meester Daughter
<br />~' 15. METHOD OF DISPOSITION 18a. EMBALMER•SIGNATURE 18b. LICENSE NO. 18t:. DATF (Mo., Day, Yr.)
<br />o
<br />~ ^ Burial ^ Donation
<br />Tracey Dietr
<br />1328
<br />September 8, 2010
<br /> ® Cremation ^ Entombment '
<br />
<br />^ Removal ^ Other (Specify) 18d. CEMt
<br />sTERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATi:
<br /> Westlawn Memprial Park Crematory Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 77b. Zlp Coda
<br /> Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br /> AU E F E ee instructions an exam es
<br /> 18. PART I. Enter the chain of events. •dliaaaea, Injudea, or compllr:atlpnaihat directly caused the death. DO NCT enter terminal evince such as cardiac arrest, APPROXIMATE INTERVAL
<br /> respiratory arreet, Or ventriGUlar fiprillatlvn without showing the atlplpgy. p0 NOT ABBREVIATE. Enter poly pna wuaa pn a Iina. Add addltlonal Ilnes If neciseary.
<br /> IMMEDIATE CAUSE: onset tc death
<br /> IMMEDIATE CAUSE (Find) a)Cardiopulmonary Arrest ;Immediate
<br /> disease or condition reeuttlnq - ~-w ...
<br /> m tleatn) DUE TO, OR AS A GONSEQUENCE OF: ; onset to death
<br /> SsquintlellylletCOndttlpna,IT b)Multi system Failure :Days
<br /> any, liatlinq to the cause listed
<br /> on Ilna a.
<br />DUE TO, OR A5 A CONSEQUENCE OF: ; onset to death
<br /> Enter the UNDERLYING CAUSE c) Septic Shock ;Days
<br /> Idleeiee Or Injury that Initiated
<br /> the svente rasultinp In death) DUE TO, 4R AS A CONSEQUENCE OF: I onset to death
<br />L°
<br />$T
<br /> '
<br />d) Infected Right Hip Hardware 3 Weeks
<br /> 18. PART IL OTHER SIGNIFICANT CONDITIONS-0onditlons cpntrlbuting to the death but not rosulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br />jY
<br />W ^ YES ®NO
<br /> 0. IF FEMALE; 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />a ^ Not pregnant wlthln peel year ®Natural ^ Homicide ^ Driver/Qpiratpr
<br />
<br />~ ^ YES ®NO
<br />^ Pregnant at time of tliath ^ Accldanl ©pinAinp Investlgatlon ^ Passenger
<br />
<br />~` ^ Not pregnant, but pregnent wkhin 42 days of death ^ PsdiaMan 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />^ Suldtla ^ Could not pa tlatarmined
<br /> ^ Not pregnant, but pregnant 49 days l0 7 year bsTors death ^ Other (apeClfy) TO COMPLETE CAUSE OF DEATH
<br /> ^ unknown If pregnant wlthln the past year ^ YE5 ^ NO
<br />~ 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, stroat, factory, office building, construction site, etc. (Specify)
<br />
<br />a 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />I'
<br />^ YES ^ NO
<br /> 22i. LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />
<br />~
<br />- _ ~ ~,4T£$~ Iy1~A7N~pCa~.1?lttlr ~_ - . _ -~ _ _ _~ ,..r- - EAIe.;~ Yr.) ., Z4b. TtM~ {?F DEATH . -- - .
<br />~`
<br /> ~ ~ 5epf®mber 3, 2010
<br />S
<br /> a r 236. DATE SIGNED (MO., Day, Yr.) 23c. TIME OF DEATH
<br />~ "' 24C. PRONOUNCED DEAD IMo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> Se tember 7, 2010 06:05 AM g ~ i Z~
<br />o
<br /> C O 9d. Tv the that Of my knowledge, death occurred at the lima, tlsti antl place $
<br />Pie. On the haNa pl examinadtln dntllor Inwetlgatlon, In my ppinlon death occurred at
<br />~ ~ and drw to the cauw(s) stated. (91gna[uro and Tkle) $
<br /> ~ the lima, tlats and place and due tp the cauei(e) etatitl. (Signature and Title)
<br /> ~ Lassa A. Woodruff, MD ~ :s
<br /> 25, pID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 286. WAS CONSENT GRANTED?
<br /> ^ YES ®NO ^ PROBABLY ^ UNKNOWN ^ YES ®NO Not Applicable B 28a Is NO ^ YES ^ NO
<br /> - R I N (ype Or r n
<br /> Lassa A. Woodruff, MD, 3219 Central Avenue, Kearney, Nebraska, 68847
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (MO., Day, Yr.)
<br /> September 7, 2010
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