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<br />WHEN . THIS <'COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />10/6/2017
<br />LINCOLN, NEBRASKA
<br />20170769 DEPARTMENT T S NT HEALTH REGISTRAR
<br />H AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Coe
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Linda Louise Greisen - Wemhoff
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Humphrey, "Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-66-8631
<br />8b. FACILITY -NAME (If not Institution, give street and number)
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<br />Nebraska Medicine
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />• Omaha 68198
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />LL 9d. STREET AND NUMBER
<br />a 4609 Deva Dr.
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<br />a . MARITAL STATUS AT l IME OF DEATH ® Married ❑ Never Married
<br />© Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
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<br />E 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />• (Yes, No or Uhk.) NO
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<br />15. METHOD OFDISPOSITION
<br />❑ Burial ❑ Donation
<br />® Cremation ❑ Entombment
<br />❑ Removal 0 Other(Specify)
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<br />in death)
<br />Enter the UNDERLYING CAUSE
<br />Idiseas# or InJer * initiated:>
<br />the events result 1 In death) ;
<br />20. IF FEMALE:
<br />▪ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Net pregnant, but pregnant within 02 days of death
<br />❑ Not prephaM,but pregnant days to 1 year before death
<br />❑ Unknown N pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d.INJURY AT WORK?
<br />}µDYES ❑NO
<br />22b. TIME OF INJURY
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES 0 NO ❑ PROBABLY ❑ UNKNOWN
<br />8a. REGISTRAR'S SIGNATURE
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />68
<br />9b. COUNTY
<br />Hall
<br />16a. EMBALMER-SIGNATURE
<br />Katie M. Smydra
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide 0 Could not be determined
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />9e. APT. NO.
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />®YES O NO
<br />2. SEX
<br />Female
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<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Arthur Greisen
<br />12. MOTHER'S -NAME (First, Middle,
<br />RoseMarie Finger
<br />Maiden Surname)
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑( Inpatient
<br />❑ ER/outpatient
<br />❑ DOA
<br />OTHER ❑ Nursing Home /LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />❑ Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Douglas
<br />9c, CITY OR TOWN
<br />Grand Island
<br />9f. ZIP CODE
<br />68801
<br />14a. INFORMANT -NAME
<br />Marvin Wemhoff
<br />16b. LICENSE NO.
<br />1454
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />September 24, 2017
<br />October 1, 1948
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Marvin Wemhoff
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />16c. DATE (Mo., Day, Yr.)
<br />September 29, 2017
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING 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 />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />CAUSE OF DEATH (See instructions and examples)
<br />IS. PART I. Enter the -Chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter events such as cardiac arrest,
<br />respiratory arrest, or VentficUlar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Respiratory Failure
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Hours
<br />Bequentialfy list conditions, d
<br />any, leading to the cause listed
<br />on line a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Liver Failure
<br />onset to
<br />Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Primary Sclerosing Cholangitis
<br />onset to death
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Coagulopathy, Obstructive Jaundice with stent, Multiple Sclerosis, Ascites
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO .
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />® YES ❑ NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES I NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />E
<br />o
<br />. DATE OF DEATH (Mo., Day, Yr.)
<br />September 24, 2017
<br />b. DATE SIt NED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />September 27 2017 10:28 PM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Cra0 A. Piauette, MD
<br />24a. DATE, SIGNED (Mo., Day, Yr.)
<br />l 24b. TIME OF DEATH
<br />PRONOUNCED DEAD (Mo., Day. Yr. ll 24d. TIME PRONOUNCED DEAD
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<br />24e. On the basis of examination and /or investigation, In my opinion death occurred at
<br />• the time, date and place and due to the cause(s) stated. (Signature and Title)
<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 />Craig A. Piquette, 982465 Nebraska Medical Center, Omaha, Nebraska, 68198 ; ,
<br />28b. DATE FILED BY REGISTRAR Mo., Day, Yr.)
<br />October 3, 2017
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