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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANQ HL4 N SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKAa~T I VF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIAL; w t ` 3 DATE OF ISSUANCE STANEEY S. COOPER 10/18/2011 2 V 1108 1! 4j ASSISFAN-gTATE E( LSTRA4 4 DEPARTME OL _J AND ' 41 LINCOLN, NEBRASKA HUMAN. SERVICES' STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 11 03427 CERTIFICATE OF DEATH 1. DECEDENTS-NAME (First, Middle, Last, Suffix) 2. SEX DATE OF. DEATH (Mo., Day, Yr.) Patricia Anne Connelly Female October'11, 2011 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) (Yrs.) MOS. DAYS HOURS MINS. Wilson, Virginia 70 May 14, 1941 7. SOCIAL SECURITY NUMBER Be. PLACE OF DEATH 229-48-0983 HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY-NAME (If not Institution, give street and number) ❑ ER/Outpatient ❑ Decedent's Home Wedgewood Care Center ❑ DOA ❑ other (specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH Grand Island 68803 Hall 0 I- U W 0 LU w z 7 a a Z 2 d d CL r t. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN Nebraska Hall Grand Island d. STREET AND NUMBER e. APT. NO. 9f. ZIP CODE 8 9g. INSIDE CITY LIMITS [3 YES ❑ NO 910 E. South Street 801 6 Da. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Edward Connelly 1. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Maiden Surname) Wallace Pruitt Nina Unknown 3. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT (Yes, No, or Unk.) No Edward Connelly Husband 5. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day,Yr.) ® Burial ❑ Donation Kevin Wood 1325 October 14, 2011 ❑ Cremation ❑ Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE ❑ Removal ❑ Other (Specify) St. Michael's Cemetery Spalding Nebraska 7a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 117b. Zip Code 68803 Livingston-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 8. PART 1. Enter the chain of events. -dlaeases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, ; APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. onset to death IMMEDIATE CAUSE: ; Immediate IMMEDIATE CAUSE (Final a) Cardiac Arrest disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Chronic Sequentially list conditions,. if b) Diffuse Vascular Disease any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: ; onset to death Ender the UNDERLYING CAUSE C) (disease or Injury that initiated ; onset to death the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) Ix W LL ix W U za}} 3S dl a E a IO- 18. PART II.OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given in PART 1. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? ® Not pregnant within past year ® Natural ❑ Homicide ❑ Driver/Operator ❑ YES ® NO ❑ Pregnant at time of death ❑ Accident ❑ Pending Investigation ❑ Passenger ❑ Not pregnant, but Pregnant within 42 days of death ❑ Suicide ❑ Could not be determined Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE ❑ TO COMPLETE CAUSE OF DEATH? ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Other (Specify) C] YES NO ❑ Unknown If pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, fans, street, factory , office building, construction site, etc. (Specify) 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED ❑ YES ❑ NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) r 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH a W October 11, 2011 r, g ~ PRONOUNCED DEAD (Mo., Day, Yr.) 24c 24d. TIME PRONOUNCED DEAD 0 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH i 0 a . o I 2011 October 11 07:47 AM E z z , ti opinion death occurred at in m n ti 8 O 3d. To the best of my knowledge, death occurred at the time, date and place W z z y , ga o 240. On the basis of examination and/or inves date and place and due to the cause(s) stated. (Signature and Title) the time o and due to the cause(s) stated. (Signature and Title) o U , ~ Richard Fruehling, MD ~ 0 s YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES N NO NAMC, 111 LC .UV V.,Vr .---,.r. I....... v,-.,- r..-., Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 REGISTRAR'S SIGNATURE A 26b. WAS GON5EN I IaKAN 1 ev r Not Applicable If 26a is NO ❑ YES ❑ NO TORNEY) (Type or Print) 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 17, 2011