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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 7/5/2018 LINCOLN, NEBRASKA RUSSELL FOSLER 2 0 8 02 V 8 a INTERIM DEPARTMENT OF HEALTH STRAR AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 18'08036' Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Leota Maraget Johnson 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) June 7, 2018 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo, Day, Yr.) Hastings, Nebraska (Yrs.) 81 MOS. DAYS HOURS MINS. July 19, 1936 7. SOCIAL SECURITY NUMBER 505-44-3697 8a. PLACE OF DEATH HOSPITAL © Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Nebraska Medicine -Bellevue 0 ER/Outpatient 0 Decedent's Home 0 DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Bellevue 68123 8d. COUNTY OF DEATH Sarpy 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER - 1022 N Custer Ave 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 0 Married, but separated, 0 Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, ; Middle, Last, Suffix) If wife, give maiden name Dale Johnson 11. FATHER'S -NAME {First, Middle, Last, Suffix) Mike Glantz 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Katherine Aschenbrenner 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Dale Johnson 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial '❑Donation 16a. EMBALMER -SIGNATURE Matthew T. Myers 1611 LICENSE NO. 1411 16c. DATE (Mo., Day, Yr.) June 13, 2018 ❑Cremation ❑Entombment ❑: Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE Westlawn Memorial Park Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston -Sondermann Funeral Home. 601 N. Webb Road. Grand Island, Nebraska 17b. ZIp Code 68803 CAUSE OF DEATH (See instructions and examples) Is. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter: terminal events such as cardiac arrest, APPROXIMATE INTERVAL 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 Stroke disease or condition resulting onset to death 7 Days in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, it b)Atrial Fibrillation any, leading to the cause listed on line a. onset to death 10 Years DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE C) (disease or injury that initiated onset to death 10 Years the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 10 Years 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. N/a 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? El YES ❑ NO 20. IF FEMALE: ❑ Not pregnant within past year Pregnant at time of death ❑❑ 21a. MANNER OF DEATH ® Natural ❑ Homicide Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO ❑ Not pregnant, but pregnant within 42 days of deathPedestrian ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year ❑ SuicideCouldnot be determined 0TO ❑ ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? '; ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by -::.. MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) June 7, 2018 To be completed by CORONER'S PHYSICIAN Tor COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 2312. DATE SIGNED (Mo., Day, Yr.) June 21 2018 23c. TIME OF DEATH 09:45 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 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) James L. Maliszewski, MD 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the causes) stated. (Signature and Title) 25. DID TOBACCO USE. CONTRIBUTE TO THE DEATH? ❑ YES El NO El PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ® YES ❑ NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ®'NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print James L. Maliszewski, MD, 986435 Nebraska Medical Center, Omaha, Nebraska, 68198 28a. REGISTRAR'S SIGNATURE i'' 28b. DATE FILED BY REGISTRAR (Mo„ Day, Yr.) June 25, 2018