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<br />1. DECEDENT'S-NAME (First, Middle, Last, Suffix)
<br />Bonnie Marie Johnson
<br />2. SEX ' 4v 3.
<br />Female
<br />dATE dpierkrAttkfo..Q y;tr}.
<br />` January 31,
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Neligh, Nebraska
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />69
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH-Mo., Day, Yr.)
<br />January 25, 1946
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />5507- 556_3428
<br />8a. PLACE OF DEATH
<br />HOSPITAL; © Inpatient OTHER: ❑ Nursing HomeILTC 0 Hospice Facility
<br />0 ER/Outpatient ❑ Decedent's Home
<br />Q D ^4 Qomer(specity)
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />CHi Health St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Aida
<br />9d. STREET AND NUMBER
<br />204 Vine Str
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68810
<br />9g. INSIDE CITY LIMITS
<br />® Yes ❑ No
<br />10a. MARITAL STATUS AT-TIME OF DEATH IX1 Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Lonnie Dean Johnson
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Leo Latzel
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Clete Legate
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, orUnk.) N
<br />14a. INFORMANT -NAME
<br />Lonnie Dean Johnson
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />Mendel °Donation
<br />°Cremation °Entombment
<br />Q Removal °Other(Speely)
<br />168. E - SIGNATURE (
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<br />16b. LICENSE NO.
<br />/ u 5 9
<br />16c. DATE (Mo., Day, Yr.)
<br />February 6, 2015
<br />• C ETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />176. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the ehaln of woofs - diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as urdiae arrest, APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add addldonal Tines if necessary,
<br />IMMEDIATE CAUSE: onset to de tit
<br />IMMEDIATE
<br />disease condition CAUSE (Final �[�, f 6' / P a hotAr-s
<br />disease or condition resulting a) 4cw f e �iZS' / O /mot e ��� 6
<br />in death) /
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to de tr
<br />Sequentially list conditions, If b) ( ` L[ ,el , f ijiVP'L
<br />any, leading to the cause listed �-- Y rrA `S1 ✓
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF: T r onset to death d d e ath
<br />Enter the UNDERLYING CAUSE c) 4 V f / � ,.. 0/- S L /V � v / . ^ d _'
<br />l� ec � �- u e ____ VVVAAA
<br />(disease or injury that Initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CO 0RIONS -C nditlons contributing to the death but not resulting in th cause given in P TT�I,
<br />CO / ONd /v) ,4 /c/ vl �f.S 2 0X C (. i(Cf CQ4C es CA { i CN f a,f 1 c f dbi c )
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<br />19. WAS MEDICAL EXAMINER
<br />O .tom Ig 1 0 'E RSNER CONTACTED?
<br />20. IF FEMALE:
<br />k Not pregnant within past year
<br />❑Pregnant at time of death
<br />❑Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑Unknown if pregnant within the past year
<br />218. MANNER OF DEATH
<br />g Nat ' ural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES 0-N0
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES %NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. N0. CITYROWN STATE ZIP CODE
<br />), IX
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<br />23a. DATE OF DEATH (Mo., Day, Yr.)
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<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
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<br />23b. .Di' DATTE SIGNED o., Day, Yr.)
<br />t7/u � cl , Ga 01I 5
<br />23c. TIME OF DEATH
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<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
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<br />2 To the bes of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
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<br />24e. On the basis of examination and/or Investigation, in my opinion death occurred
<br />at the time, date and place and due to the cause(s) stated. (Signature and Title)
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<br />25. DID TOBACCO USE CONTRI E TO THE DEATH?
<br />❑ YES at NO ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YES $] NO
<br />j 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Jeffrey King, MD 3515 Richmond Circle, Grand Island, NE 68803
<br />28a. REGISTRAR'S SIGNATURE /
<br />l��iika i. U96,
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />FEB 9 2015
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<br />STATE OF NEBRASKA 201504:924
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR taTAc. OORVS.`
<br />DATE OF ISSUANCE
<br />FEB 202015
<br />LINCOLN, NEBRASKA
<br />A6SIgI ANT;,S f. rgStaA ';'
<br />d nyE F H ANEY' '
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERIIIC'„$ *`. 1, '
<br />CERTIFICATE OF DEATH j , ># r ` -
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