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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 />7/24/2019
<br />LINCOLN, NEBRASKA
<br />201904936 RUSSELL FOSLER
<br />ASSISTANT T T EOR EGISTRAR
<br />R
<br />DEPTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE QF 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 />Janet Marie Donahe r_
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 9, 2015
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Sa. AGE - Last Birthday
<br />$b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Bloomfield, Nebraska
<br />(ars.)
<br />65
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />Februa 9 1949
<br />7. SOCIAL SECURITY NUMBER
<br />508.68.3557
<br />Be, PLACE QF DEATH
<br />HOSPITAL ❑ Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />Bb. FACILITY.NAME fir not Institution, give street and number)
<br />Park Place -A Golden Living Center
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8e. CITY OR TOWN OF DEATH (Ineiude Zip Codc)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Ha!!
<br />ga. RESIDENCE•STATE (9b. COUNTY
<br />Nebraska I Hall
<br />8c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER 1Se. APT. NO.
<br />607 W. Ave II
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 N1
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married
<br />❑ Married, but separated r 0 Widowed 0 Divorced 0 Unknown
<br />100. NAME QF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Dwight James Donahey
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Robert Frank Case
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Esther Schroeder
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Link,) No.
<br />14a. INFORMANT -NAME
<br />Dwight James Donahev
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE 1612. LICENSE NO.
<br />Not Embalmed 1
<br />16c. DATE (Mo., Day, Yr.)
<br />January 13, 2015
<br />® Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services 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 DEAT 1JSee instructions and examples
<br />18. PART I. Enter the: Cham of events --disease:, inhales, or complications -that directly caused the death. DO NOT anter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrant, or ventricular libriliation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilea. Add additional tine if necessary.
<br />!MG: MATE CAUSE_
<br />IMMEDIATE CAUSE (Final a)Widely Metastatic Cancer Unknown Primary
<br />disease or condition resulting
<br />onset to death
<br />6 Months
<br />to death/
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially het conditions, if ' b)
<br />any, leading to the cause gated
<br />onset to death
<br />on line a:DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE c)
<br />(disease of injury Mat Initiated'
<br />thea went. reeultmg in daatIt DUE TO, OR AS A CONSEQUENCE OF; onset to death
<br />LAfiT' d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Depression, Obesity
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ENO
<br />20. IF FEMALE:
<br />E Not pregnant within pant year
<br />❑ Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />Pending Investigation
<br />210. IF TRANSPORTATION INJURY
<br />0 CAvrr/Operator
<br />Passenger
<br />❑ g
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />❑ Not pregnant, but pregnant within 42 days of death❑
<br />0 Not pregnant, but pregnant 43 days to 1 year before depth
<br />0 unknown If prsgnao within the past year,..,
<br />❑ Accident ❑
<br />08u ci to determinedCould not daterm°d
<br />Pedestrian
<br />❑ Other (Specify)
<br />--0
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />vs,& 0 NO
<br />22a. DATE OF INJURY (Me., 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 ATWORK? : ;
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be completed by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 9. 2015
<br />To be completed by
<br />CORONERS PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 12, 2015
<br />23e. TIME OF DEATH
<br />04:45 PM
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.
<br />24d. TIME PRONOUNCED DEAD
<br />23d. To the beat of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Larry L. Hansen, 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 ED NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES R NO
<br />26b. 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 />Larry L. Hansen, MD, 3016 West Faidiey, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />. UHIC r,LCV OT RCViO mnr�lmvq Vey, ,,,./ -
<br />January 14, 2015
<br />
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