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STATE OF NEBRASKA WHEW ! 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 3/3/2017 LINCOLN, NEBRASKA 201703058 ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH! AND HUMAN SERVICES CERTIFICATE OF DEATH Exhibit "A" 8b, FACILITY -NAME (If not Institution, give street and number) it CHI Health St, Francis I te i 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 z D LL .0 0. 0 at 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Merleen Jean Johnson 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH North Platte, Nebraska 7. SOCIAL SECURITY NUMBER 508 -26 -9297 9a, RESIDENCE -STATE Nebraska 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated ; ® Widowed ❑ Divorced ❑ Unknown 13. 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) DUE TO OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease Or injury that inalated the events rasvlt death) LAST 20. IF`FEMALE: ❑ Not pregnam within •past year ❑ Pregnant at time of death ❑ NM pregnaMrbut pregnant w thin 42 days of death Not pregnant, out pregnanl43 days to 1 year before death • ❑ Unknown if pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 23a. DATE OF DEATH (Mo., Day, Yr.) February 20 2017 It it 0- la .J 3 U J z 4 0 3d. To the best of my knowledge, death occurred at the time, date and place 2 .9 and due to the causais) stated, (Signature and Title) o )enrifer t ., Btown, MD 23b. DATE SIGNED (Mo., Day, Yr.) February 21, 2017 23c. TIME OF DEATH 04:20 PM 25. Otf3 TOBACCO USE CONTRIBUTE TO THE DEATH? ❑'YES 10 NO ❑ PROBABLY ❑ UNKNOWN `S 5a. AGE`- Last Birthday (Yrs.) 90 9b. COUNTY Hall 5b. UNDER 1 YEAR MO S. 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA 9d. STREET AND NUMBER 1808 West 2nd Street 16a. EMBALMER- SIGNATURE Chris McCoy 9c. CITY OR TOWN Grand Island ffi 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name,, Robert James Johnson 11. FATHER'S -NAME (First, Middle, Last, Suffix) George Frederick Geisert 12. MOTHERS -NAME (First, Middle, Maiden Surname) Treva Winifred Dressler 14a. INFORMANT -NAME Brad Johnson 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be detemtined 16b. LICENSE NO. 1191 16d. CEMETERY, CREMATORY OR OTHER LOCATION Blue Valley Cemetery CITY /TOWN Ayr STATE Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State):': Aofel Funeral Home, 1123 W. 2nd, Grand Island. Nebraska CAUSE OF DEATH (See instructions and examples) 13. PART I. Enter the Chairs of events - -diseases, injuries, or complications -that directly caused the death. 00 NOT enter terminal 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) Respiratory Failure disease or condition resulting in death) Sequentially list COaditions, if any, leading to the cause bated on line a - DUE TO, OR AS A CONSEQUENCE OF: b) Multiple Myeloma APPROXFMATS INTERVAL.. onset to death < 1 Week'` onset to death > 1 Month onset to death DUE TO, OR AS A CONSEQUENCE OF: d) 18, PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Congestive Heart Failure 21b. IF TRANSPORTATION INJURY Driver /Operator ❑ Passenger 0 pedestrian other (Specify) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc, (Specify) 22d. INJURY AT WORK? YES (3 NO t 2 2e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 10 NO 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 24c.' PRO N OUNCED DEAD (Mo., Day, Yr.)f 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) 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jennifer t :; Brown., MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR S IGNATURE DAYS 9e. APT. NO. 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68803 3. DATE OF DEATH (Mo., Day, Yr.) February 20, 2017 6. DATE OF BIRTH (MO.c Day, Yr.) November 4,1926 ❑ Hospice Facility 9g, INSIDE CITY LIMITS 121 YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Son 16c. DATE (Mo., Day, Yr.) February 25, 2017 17M210 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® 21c. WAS AN AUTOPSY PERFORMED/ ❑ YES 1 NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? ❑ YES ❑ NO " 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (M Day. Yr.} February 27, 2017