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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 /S THE LEGAL DEPOSITORY FOR VITAL RECORDS if RUSSELL 20190 3689 ASSISTANT STATEEREGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH DATE OF ISSUANCE 5/7/2019 LINCOLN, NEBRASKA Pursuant to section 30-2413, demands for notice which may affect the estate of the decez•sed 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) Joanne Eloise Nielsen 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) Found April 26, 2019 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.) 92 MOS. DAYS HOURS MINS. May 30, 1926 7. SOCIAL SECURITY NUMBER 506-26-8500 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) 3027 W. Capital Ave, Apt. 31 0 ER/Outpatient E Decedent's Home 0 DOA 0 Other (Specify) 3c r!Tv op TOWN OF DE?TH (Include lin Codel 18d. COUNTY OF DEATH Grand Island 68803 I Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 3027 W. Capital Ave 9e. APT. NO. 31 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑';Married, but separated E Widowed ❑ Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Rilley Nielsen` 11. FATHER'S -NAME (First, Middle, Last, Suffix) John Lassen 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Elsa Windolph 13. EVER IN U.S, ARMED FORCES? Give dates of service if Yes. (Yes, No, or unk.) No 14a. INFORMANT -NAME Connie Nielsen 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION E Burial ❑Donation 16a. EMBALMER -SIGNATURE Stacie L Ruiz 16b. LICENSE NO. 1495 16c. DATE (Mo., Day, Yr.) April 30, 2019 ❑ Cremation 0 Entombment ❑ Removal <❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING 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) 15. 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 R necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Unknown disease or condition resulting onset to death in death) <. DUE TO, OR AS A CONSEQUENCE OF: any, leading to the :;emanated line onset to death on a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or Injury that initiated:. onset to death the events resulting in Beata) : DUE TO, OR AS A CONSEQUENCE OF: LAST; d) onset to death 18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Unknown Due To Oki Age 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? E YES ❑ NO 20. IF FEMALE: 0 Not pregnant within past year Pregnant at time of deathPassenger 0 21a. MANNER OF DEATH E Natural 0 Homicide 0 Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 21c. WAS AN AUTOPSY PERFORMED? El YES E NO ❑ Not pregnant, but pregnant within 42 days of death ❑..Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown R: pregnant within the past year 0 Suicide 0 Could not be determined 0 Pedestrian 0 Other (Specify) 21 d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ 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. INJURY OYES AT WORK? 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL "lERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY OF'LY 24a. DATE SIGNED (Mo., Day, Yr.) May 6, 2019 24b. TIME OF DEATH Unknown 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr. P.pril 2_,' 2010 24d. TIME PRONOUNCED DEAD OS:12 PM J. 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) 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) Martin Klein, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES 0 NO 0 PROBABLY E UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES E NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Martin Klein, Hall Deputy County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801 28a. REGISTRAR'S SIGNATURE ^- - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) May 7, 2019 ': 'r"r