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` r. + /,'31 Alatv.Y ,+, ,N, , . i d 4)4 . .ro STATE OF NEBRASKA watInix Yio 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 DATE OF ISSUANCE 2/23/2017 LtNCOL'N, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Jackie Duane O'Hara 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Yankton, South D akota 7. SOCIAL SECURITY NUMBER 506 -40 -1357 FACILITY -NAME Of not 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 5137 South Engleman Road IMMEDIATE CAUSE (Final disease or condition resulting Enter the UNDERLYING CAUSE (tlisease Of injury P1St initiated: the events resulting:(n death) La . 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death 22d. INJURYATWORK7 YES NO DATE 23b. DAM SIGNED'(Mo., Day, Yr.) STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 9b. COUNTY Hall 5a. AGE . Last Birthday (Yrs.) 81! 14a. INFORMANT -NAME DeAnne Lorraine O'Hara 16d. CEMETERY, CREMATORY OR OTHER LOCATION Grand Island City Cemetery 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska IMMEDIATE CAUSE: a) Cardiopulmonary Arrest DUE TO, OR AS A CONSEQUENCE OF: c) Coronary Artery Disease DUE TO, OR AS A CONSEQUENCE OF: d)Type 2 Diabetes 201.70284g STANLEY S. DPER ASS STANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient I! ER/Outpatient ❑ DOA In death) DUE TO, OR AS A CONSEQUENCE OF: S equentiasy list conditions, if !fi b) Motor Vehicle Accident Blunt Force Trauma To Torso !. any, leading to the cause listed on line a. 9c. CITY OR TOWN Grand island' MOS. 5b; UNDER 1 YEAR DAYS 9e. APT. NO. Emma Lehman 16b. LICENSE NO. 1397 2. SEX Male 5c. UNDER 1 DAY HOURS CITY / TOWN Grand island 214. IF TRANSPORTATION INJURY £ El Driver /Operator ❑ Passenger 21a. MANNER OF DEATH ❑ Natural ❑ Homicide ® Accident ❑ Pending Investigation ❑ Not pregnant, but pregnant within 42 days of death ❑ Pedestrian ❑ Suicide ❑ Could not be determined ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Other (Specify) ❑ Unknown if pregnant within the past year MINS. 9f. ZIP CODE 68803 8d. COUNTY OF DEATH Hall OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other(Specify) 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Hypercholesteremia, Anxiety, History Of TIA, Hypothyroidism, Prostate Cancer, Bilateral Femur Fractures, Abdominal Trauma, Circulatory Problems & Left Foot Ulceration Secondary To Diabetes 3. DATE OF DEATH (Mo., Day, Yr.) February 8, 2017 6. DATE OF SIR August 17 1935 Oa. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden rasing 0 Married, biitseparatert 0 Widowed 0 Divorced ❑Unknown DeAnne Lorraine Jorgensen 4' it FATHERS -NAME (Prat, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Maiden Surname) d Merle O'Hara 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No .2 15. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE I �. ® Burial 0 Donation Laurie D. Sheffield 0 Cremation ❑ Entombment 0 Removal .❑ Other (Specify) 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., DayYr.) February 13, 2017 STATE Nebraska 171s: 2:ip.Code 68801 • CAUSE OF DEATH (See instructions and examples) 8. PART I. Enter the chain or evetins- diseases, injuries, or complications -that directly caused the death. 00 NOT enter temilnat events such as cardiac arrest, APPROX#MATE:7 respiratory errest,or ventnyyltar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one Cause on a tine. Add additional lines H necessary. onset to death Minutes onset to dea Seconds onset to death Years onset to heath Years 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ No 21c. WAS AN AUTOPSY PERFORMED? ❑ YES NO 21d. WERE AUTOPSY . FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a, DATE OF INJURY (Mo., Day, Yr.) 122b. TIME OF INJURY 1 22c. PLACE OF INJURY -At home. farm, street, factory. office building. construction site, etc. (Specify) February 8, 2017 1 03:08 PM 1 Street 22e. DESCRIBE HOW INJURY OCCURRED One vehicle motor vehicle accident rolloverwith driver trapped inside vehicle. Decedent's car struck a light pole. npcprlpnt ciiffprprl cpvprp trauma to tr rcn!Anrl hnrl 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. Hwy 281 & Capital Avenue, Grand Island OF DEATH (Mo., Day, Yr.) CITY/TOWN 23c. TIME OF DEATH 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) 28a. REGISTRARS SIGNATURE 0 STATE Nebraska 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH February 14, 2017 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD Approx. 03:15 PM ❑ Hospice Facility 9g. INSIDE CITY LIMITS ❑ YES ® NO ZIP CODE° 68803 February 8, 2017 04:03 PM 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) Nancy Berner- Schneider, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED ? 26b. WAS CONSENT GRANTED? ❑ YES Q NO ❑ PROBABLY ® UNKNOWN ❑ YES ® NO Not Applicable if 26a is NO ❑ YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Nancy Berger-Schneider, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) February 14, 2017 (Mo., Day, Yr.)