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WHEN THIS co"PY 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 1p%aL�, NEBRASKA RUSSELL FOSTER 2 010 0 3 3 3 2 INTERIM ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1812784 Pursuant to sec,ion 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the countywhere the decedent resided at the time of death. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Erin Eileen Jordan 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) October 3, 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.) Grand Island, Nebraska (Yrs.) 60 MOS. DAYS HOURS MINS. October4, 1957 7. SOCIAL SECURITY NUMBER 505-80-1569 8a. PLACE OF DEATH HOSPITAL © Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health $t. Francis 0 ER/Outpatient 0 Decedent's Home 0 DOA 0 Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) l ud. COUN f Y O$ uEATH Grand Island 68803 I Hall 9a, RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1911 N Sheridan Avenue 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married ❑ Married, but separated, ❑ Widowed ❑ Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Russell Thomas Jordan 11. FATHER'S -NAME (First, Middle, Last, Suffix) - Clarence Gosda 12. MOTHER'S -NAME (First, Middle, Maiden Surname) TJaunita Snyder 13, EVER IN U.S. ARMED; FORCES? Give dates of service if Yes. (Yes, No, or Unit.) No 14a. INFORMANT -NAME Russell Thomas Jordan 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑Burial 0 Donation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) October 9, 2018 ® Cremation 0 Entombment ❑ Removal J Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska 17b.Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 1s. PART1. Enter the [Bain 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 addition! lines R necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting onset to death <24 Hours DUE :), OR AS A :0Ns_QJEr'c2 OF: onset to death .' Sequentially inn 6onrntiens, it _-b) E Coli And Proteus Bacteremia ; < 24 Hours any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: Enter the. UNDERLYING CAUSE c)Sepsis (disease or injury that initiated onset to death <24 Hours the ey5015 resuamgl,10 death) 'd DUE TO, OR AS A CONSEQUENCE OF: LAST ; d)Neutropenia Fever onset to death <24 Hours 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Cholecystitis, Metastatic Breast Cancer 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE: ® Not pregnant within past year 0 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? 0 YES ®NO ❑ Not pregnent, put pregnant within 42 days of death 0 Not pregnant, tint pregnant 43 days to 1 year before death 0 Unknown if pregnantwithin the past year 0 Suicide 0 Could not be determined ❑ Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 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. INJURYATWORK? ❑YES ONO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE Tube completed by MEDICAL CERTIfI .R ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) firinh tar '2 7f11 Ft To be complet' 7y. CORONER'S PHN Sll IAN or COUNTY ATlOR VEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 124b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) October 4, 2018 23c. TIME OF DEATH 01:12 PM 24c. Po 101!F!CED DEAD (Mo., Day, Yr.)! 24d. TIME PRONOUNCED DEAD 1 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Jennifer L. Brown, 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 cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES ® NO 0 PROBABLY 0 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 Jennifer L, Brown„ MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE fit'-") C"----------- 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 9, 2018 rr�