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To be completed /verified by: FUNERAL DIRECTOR
<br />1
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Joanne Lee Rasmussen
<br />2. IX' j
<br />Fen - 1416 , .y / r
<br />�3. 3ATE OR,dt:ATH (Mo., Day, Yr.)
<br />I Matiti 11'7 '2015
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Boulder, Colorado
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />85
<br />5b. UNDER 1 YEAR
<br />5c. UNDE4 1 DA 6.
<br />DATE, BIRTH (Mo., Day, Yr.)
<br />August 8, 1929
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />523 -38 -3244
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />❑ DOA ❑ Other(Specify)
<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 />Grand Island
<br />9d. STREET AND NUMBER
<br />557 Stagecoach Road
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® 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 />Jack E Rasmussen
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Ernest Laurelle Fundingsland
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Alice Lucille Fields
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Jack Rasmussen
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑ Donation
<br />® Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. EMBALMER- SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />March 14, 2015
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />To be completed by: CERTIFIER I
<br />18. PART I. Enter the chain of events - , diseases, injuries, or compiicationsdhat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />< 1 Day
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Respiratory Failure
<br />disease or condition resulting
<br />in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />Sequentially list conditions, if b) End Stage Renal Disease i > 1 Year
<br />any, leading to the cause listed 1
<br />1
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />Enter the UNDERLYING CAUSE c) 1
<br />(disease or injury that initiated ;
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />LAST d) 1
<br />1
<br />e
<br />18. PART ll. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given In PART 1.
<br />Malnutrition
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE:
<br />❑ 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 />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide 0 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 ® NO
<br />21 d. 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 />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.NO. CITY/TOWN STATE ZIP CODE
<br />EW
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<br />1 3,
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<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 11,2015
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<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />March 2015
<br />23c. TIME OF DEATH
<br />07:45 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />O J
<br />u ¢ 23d. To the best knowledge, death occurred at the time, date and place
<br />o w and duo to th e cause(s) causes) stated. (Signature a nd Title) )
<br />3: Jennifer L. Brown, MD
<br />24e. On the basis of eaamination and /or investigation, ca ) in my opinion death occurred at
<br />the time, date and place and due to the uses stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 17 NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jennifer L. Brown, MD, 729 North Custer Avenue,
<br />Grand Island, ebraska, 68803
<br />1 28a REGISTRAR'S SIGNATURE -'
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 18, 2015
<br />J
<br />DATE OF ISSUANCE
<br />03/24/2015
<br />STATE OF NEBRASKA
<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 DPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RE'CORb.5.
<br />STANLEY'S. COOPER .
<br />ASSISTANT STATE REGISTRA
<br />PMARThtENT OF HEALTH A ,
<br />LINCOLN, NEBRASKA v "H�J'Q1i,AN
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN+S/ICES
<br />CERTIFICATE OF DEATH ti
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