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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 /S THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />6/3/2019
<br />LINCOLN, NEBRASKA
<br />REGISTRAR
<br />RUSSELL FOSLER
<br />201903487 A DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />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.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Joyce Ann Fotinos
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />May 11, 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 />St. Paul, Nebraska
<br />(Yrs.)
<br />87
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />May 8, 1932
<br />7. SOCIAL SECURITY NUMBER
<br />508-32-8881
<br />8a. PLACE OF DEATH
<br />HOSPITAL © Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA ❑ Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />_Grand
<br />9a, RESIDENCE-STATE9b. COUNTY Sc.CITY OR OWN
<br />Nebraska I Hall Wood River
<br />9d. STREET AND NUMBER
<br />2802 S 110th Rd
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />9g. INSIDE CITY LIMITS
<br />IX, YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />❑ Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Pete Fotinos
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Edward Becker
<br />12. MOTHER'S NAME (Fir t. Midd!a, Maiden Surname)
<br />Bregida Sack
<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 />Janice Budd
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑Donation
<br />16a. EMBALMER -SIGNATURE
<br />Matthew T. Myers
<br />1613. LICENSE NO.
<br />1411
<br />16c. DATE (Mo., Day,Yr.)
<br />May 16, 2019
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Livingston -Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska
<br />17b. Zip Code
<br />68803
<br />CAUSE OF DEATH (See instructions and examples)
<br />16. 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 if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Hypoxic Hypercarbic Respiratory Failure
<br />disease or condition resulting
<br />onset to death
<br />Weeks
<br />indeath) DUE TO, OR AS A CONSEQUENCE OF: ' onset to death
<br />Sequentially let conditions, if b)Chronic Obstructive Pulmonary Disease ; Years
<br />any, heading tome kauve hated
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury: that initiated.:
<br />onset to death
<br />the events resulting In death) ' DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<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 />Dysphagia With Aspiration Risk, Atrial Fibrillation, Diabetes, Hypertension, Coronary Artery Disease S/P Coronary Artery
<br />Bypass Graft, Parkinson's Disease, Depression With Anxiety
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES ® NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED'?
<br />0 YES ®NO
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 'Unknown it pregnant within the past year
<br />0 SuicideCould not be detemtined
<br />0
<br />❑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 INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be completed by
<br />MEDICAL :ERTIFIER.
<br />OItLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 11, 2019
<br />To be cc.npleted by
<br />CORONER'•; PHYSICIAN
<br />or COUNT( ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />2413. TIME OF DEATH
<br />23b. DATE SIGNEb (Mo., Day, Yr.)
<br />May 30, 2019
<br />23c. TIME OF DEATH
<br />11:47 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Title)
<br />Kimberly A. Mickels, MD
<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 />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES EJ NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ONO
<br />2613. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Kimberly A. Mickels, MD, 729 North Custer Avenue,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />May 31, 2019
<br />"'
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