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DOUGLAS COUNTY WHEN THIS COPY CARRIES THE RAISED SEAL OF DOUGLAS COUNTY, NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE DOUGLAS COUNTY HEALTH DEPARTMENT VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS AA-. .�. ADI POUR 20170108 e HEALTH DOUGLAS DIRECTOR COUNTY HEALTH DEPARTMENT STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH DATE OF ISSUANCE 10/12/2016 OMAHA, NEBRASKA 1. DECEDENTS - NAME (First, Middle, Last, Suffix) Beatrice Louise Gjertsen 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Middlesex County, Massachusetts 7. SOCIAL SECURITY NUMBER 013 -20 -0078 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health Lakeside 8c. CITY OR TOWN OF DEATH (Include Zip Code) Omaha 68130 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 4147 Driftwood Drive 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Wesley C Urquhart 3. EVER IN U.S, ARMED FORCES? Give dates of service if Yes. (Yes, No or Unk.) No 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation [❑ Entombment ❑ Removal ;© Other (Specify) 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Arbor Society. Inc.. 2819 South 125 Avenue. Suite 367. Omaha. Nebraska CAUSE OF DEATH (See instructions and examples) 18. PART 1. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter events such as cardiac arrest, 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) Ischemic Colitis disease or condition resulting in deathj- Sequentially list conditions, if any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease or injury Initiated:,. the events resulunq:in death) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. (X Id , 20. IF FEMALE: CC ❑Not pregnant within past year U ❑Pre gnant at time of death ❑ Not pregnant, but pregnant withi 42 days of death ❑ Not pregnant, but preanant43 days to 1 year before death ❑ Unknown ifpregnaru wahin the past year 223. DATE OF JURY ( Mo., May, Yr.) d. INJURY ATWORK? []YES NO 22f. LOCATION OF INJURY STREET &NUMBER, APT.NO. 23a. DATE OF DEATH (Mo., Day, Yr.) October 5, 2016 23b. DATE SIGNED (Mo., Day, Yr.) October 7, 2016 8a. REGISTRAR'S SIGNATURE 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Not Embalmed 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Autumn Hills Cremation Services Omaha STATE Nebraska DUE TO, OR AS A CONSEQUENCE OF: b)Vascular Disease DUE TO, OR AS A CONSEQUENCE OF: c) Type II Diabetes Mellitus DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF I"JJ .JrtV 5a. AGE - Last Birthday (Yrs.) 91 10b. NAME OF SPOUSE (First, ; Middle, Last, Suffix) If wife, give maiden name John Walter Gjertsen 14a. INFORMANT- NAME Carolyn G Huibregtse 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 1 22c. ?LACE O' INJURY At hems, form, street, facto:,+, office building, cceetructloa sits, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 23c. TIME OF DEATH 12 •25 PM 3d. To the best of my knowledge, death oecuned at the time, date and place and due to the cause(s) stated. (Signature and Title) Heather M. Morgan, MD CITY/TOWN E °a- N Z u re 2 2 z 1 2 8 o a v r 5b. UNDER 1 YEAR MOS. DAYS HOURS 9e. APT. NO. 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Josephine Goodwin 16b. LICENSE NO. 21b. IF TRANSPORTATION INJURY 0 Oliver/Operator ❑ Passenger El Pedestrian Wier (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 7 NO 2 5. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES El NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Heather M. Morgan, MD, 16909 Lakeside Hills Court, Ste 300, Ornaha, Nebraska, 68130 2. SEX Female 5c. UNDER 1 DAY 9f. ZIP CODE 68803 STATE MINS. 3. DATE OF DEATH (Mo., Day, Yr.) October 5, 2016 6. DATE OF BIRTH (M June 21, 1925 Day, Yr.) 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/Outpatient © DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Douglas 9c. CITY OR TOWN Grand Island 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Daughter 16c. DATE (Mo., Day, Yr.) October 7, 2016 1711. Zip Code 68144 A PPROX(MATEiINTERVAL onset to death Days onset to death Years onset to death Years onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES RI NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD • 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) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 11, 2016