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STATE OF NEBRASKA
<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 />4/24/2019
<br />LINCOLN, NEBRASKA
<br />Amended
<br />201902720 RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />19 03451
<br />am filed with the county court in the county where the decedent residedat the time of death. 1
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Lola Mae Clark
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />March 13, 2019
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)'
<br />Alda, Nebraska
<br />(Yrs.)
<br />82
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />August 7, 1936
<br />7. SOCIAL SECURITY NUMBER
<br />505-44-3621
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St FfancIe
<br />E ER/Outpatient 0 Decedent's Home
<br />0 DOA0 Other(Specify)
<br />- - ------
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) 1 8d. COUNTY OF DEATH
<br />Grand Island 68803 I Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Dannebro_
<br />9d. STREET AND NUMBER
<br />11381 Loup River Rd W
<br />e. APT. NO.
<br />9f. ZIP CODE
<br />68831
<br />9g. INSIDE CITY LIMITS
<br />❑ YES E NO
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married
<br />❑':Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Stephen D Clark
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Harry Schwieger Mildred Thesenvitz
<br />13. EVER IN U.S. ARMED: FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Stephen Clark
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />15. METHOD OF. DISPOSITION
<br />E Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />16b. LICENSE NO.
<br />1454
<br />16c. DATE (Mo., Day, Yr.)
<br />March 26, 2019
<br />❑ Cremation 0 Entombment
<br />❑ Removal ;❑ Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Riverside Cemetery Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING 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 />CAUSE OF DEATH (See instructions and examples)
<br />18. 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,
<br />APPROXIMATE INTERVAL.
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines 8 necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Cardiac Arrest
<br />disease or condition resulting
<br />onset to death
<br />Minutes
<br />M death/ DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially 1/81 Conditions, it b)Asystole
<br />any, leading to the cause listed
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) Respiratory Arrest
<br />((Ssease orittjury that initiated
<br />the events resutti spin death) ;: f DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST... '.; d)
<br />onset to death
<br />Minutes
<br />onset to death
<br />Minutes
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Hypoxemia
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />E YES ❑ NO
<br />20. IF FEMALE:.
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant,bid pregnant 43 days to 1 year before death
<br />❑.Unknown i1 pregnant within the past year
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />❑ Accident ❑ Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑ Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ENO
<br />❑ Suicide 0 Could not be determined
<br />0 Pedestrian
<br />< 0 Other (Specify(
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW (NJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (a'.o.. Day. Yr.)
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE S(G:=FD (Mo., Day. Yr.)
<br />March 15, 2019
<br />241.' TIME OF DEATH
<br />05:26 AM
<br />:o sec.
<br />mpleted
<br />CERTIWI
<br />VLY
<br />N
<br />w
<br />C
<br />D
<br />GT;
<br />Z
<br />m'
<br />0
<br />0
<br />v
<br />m
<br />23c. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />March 13, 2019
<br />24d. TIME PRONOUNCED DEAD
<br />05:26 AM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />i2and due to the cause(s) stated. (Signature and Title)
<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 />Kate Collins, Hall Deputy County Attorney
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY E UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Kate Collins, Hall Deputy County Attorney, 231
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES E NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />S. Locust, Grand Island, Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATURE77
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />March 19, 2019
<br />Amended
<br />4/24/2019 Item 9b County Of Residence Corrected From Howard To Hall
<br />
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