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To be completed /verified by: FUNERAL DIRECTOR I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Donna Jean Johnson 2. SEX ' ' ! + ' ' Female 3. DATE,OF DEATH (Mo., Day, Yr.) •, 'January 6, 2016 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Dallas, Texas 5a. AGE - Last Birthday (Yrs.) 54 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) October 21, 1961 MOS. DAYS HOURS MINS. I 7. SOCIAL SECURITY NUMBER 505 -94 -3917 8b. FACILITY -NAME (If not Institution, give street and number) 217 North Carey 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 217 North Carey 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated ® Widowed ❑ Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Steven Johnson 11. FATHER'S -NAME (First, Middle, Last, Suffix) Don Holland 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Shirley Fox 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Justin Johnson 14b. RELATIONSHIP TO DECEDENT Son 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) January 8, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER I 18. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death 12 Months respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Metastatic Renal Cell Carcinoma disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b) 1 any, leading to the cause listed I 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: � onset to death Enter the UNDERLYING CAUSE c) I (disease or injury that initiated I the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LAST d) I 1 t. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 2. IF FEMALE: ® Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE npleted by CERTIFIER ■1LY 23a. DATE OF DEATH (Mo., Day, Yr.) January 6, 2016 To be completed by CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) January 7, 2016 23c. TIME OF DEATH 06:55 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 123d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Richard Fruehling, MD 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN { ❑ YES 0 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand I land, raska, 68803 r 1 28a. REGISTRAR'S SIGNATURE /)1� A- ap ` __ v �lvv 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) January 11, 2016 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OFHEALTH-AND k/4MAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAS 1DP , Ik1ENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL 8g R(SS DATE OF ISSUANCE 201601040 STANLEY S. COOPER r A T, SISTANTS T - REGISTRAR DEPAReM T i� HEALTH AND LINCOLN, NEBRASKA HUMAN SERVICES • STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SOtylcri r.T p CERTIFICATE OF DEATH ' >- • 01/14/2016