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isha AA idois fAsymmta IAA tat LY ce u 0. E 0 u m 0 o death) WHEN !' THIS !!' COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS 201/02272 DATE OF ISSUANCE 12/28/2016 LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Ida Gertrude Brokaw 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Washington, Nebraska 7. SOCIAL SECURITY NUMBER 507 -46 -1061 b. FACILITY -NAME (Knot Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 1803 S. Garland 1Qa. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Claus A Sass 13. EVER; IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No or Utk.) No .. 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal ❑ Other(Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston- Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska CAUSE OF DEATH (See instructions and examples) 4. PART 1. Enter the chain of events- - diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, orventtictiiar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause '. on a line.: Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIA IE CAUSE (Final a)Acute Respiratory Distress Syndrome disease or condition resulting Sequentiallytist conditions, if is any leading to the cause gated on line a. Enter the UNDERLYING CAUSE (disease •dr injury that initiated the eveh[s resvmrtg in death) LAST; 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Acute Renal Failure,Anoxic Brain Injury,Atherosclerotic Cardiovascular Disease, SA Node Dysfunction 20. tFFEMALE: ❑ Not pregnant'within past year ❑ Pregnant at time of death Notpregnant; pregnant within 42 days of death ❑ Not pregnant, tut prsgnant83 days to 1 year before death ❑ Unknpwn if pr the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 2d. INJURY AT WORK? p YES CJ NQ 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. U Z O 2 23a. DATE OF DEATH (Mo., Day, Yr.) December 5 2016 25b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH December 6, 2016 12:11 PM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Steve Husen, MD STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 9b. COUNTY Hall 16a. EMBALMER-SIGNATURE DUE TO, OR AS A CONSEQUENCE OF: C) DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 5a.. AGE -Last Birthday (Yrs.) 10b. NAME OF SPOUSE (First, _ Middle, Edward Dean Brokaw 14a. INFORMANT- NAME Edward Dean Brokaw Gwen K. Hvronemus 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Memorial Park Crematory DUE TO, OR AS A CONSEQUENCE OF: b)Severe Aspiration Pneumonia With Sepsis 83 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ EPJOutpatient ❑ DOA 21a. MANNER OF DEATH ® Natural Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined: 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) CITY /TOWN 5b. UNDER 1 YEAR MOS. 9c. CITY OR TOWN Grand Island DAYS STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 9e. APT. NO. 2. SEX Female 5c. UNDER 1 DAY HOURS 16b. LICENSE NO. 1448 CITY / TOWN Grand Island MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68803 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Calista L Pearce 21b. IF TRANSPORTATION INJURY ❑ Orlver /Operator ❑ Passenger ❑ Pedestrian ❑ Other(Specify) STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES II NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 ale 1610 3. DATE OF DEATH (Mo., Day, Yr.) December 5, 2016 March 3, 193 Last, Suffix) if wife, give maiden name 24b. TIME OF DEATH 24d. TIME PRONOUNCED D 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) 28b. DATE FILED BY REGISTRAR (M0, Day, Yr.) December 14, 2016 559 6. DATE OF BIRTH (MO.. Day, ?t ); ❑ Hospice Facility 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) December 8, 2016 STATE asks 17b. Zip Code 68803 APPROXIMATE INTERVAL onset to death 4 Days onset to death 4 Days onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES al NO 21c. WAS AN AUTOPSY PERFORMED ?:: ❑ YES ® NO 26b. WAS CONSENT GRANTED'? 4' Not Applicable if 26a is NO ED YES ❑ NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ?. ❑ YES ❑ NO