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<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 />10/10/ 2019 201906531>
<br />DATE OFISSUANCE
<br />LINCOLN, NEBRASKA
<br />G�-
<br />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 />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Gloria Jean Presnell
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />October 1, 2019
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Fremont, Nebraska
<br />5a. AGE- Last Birthday
<br />(Yrs.)
<br />85
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr.),
<br />May 12, 1934 €'
<br />7. SOCIAL SECURITY NUMBER
<br />507-36-4842
<br />80. FACILITY -NAME Of not Institution, give street and number)
<br />Westfield Quality Care
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Aurora 68818
<br />98. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET ANDNUMBER
<br />2612 W. 13th Street
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />ER/Outpatient
<br />DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (specify)
<br />8d. COUNTY OF DEATH
<br />Hamilton
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />0 Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0' W10104, 134 separated; 0 Widowed 0 Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Clinton Presnell
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Frank Krings
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Alice Westphal
<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 />Clinton Presnell
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />® Cremation 0 Entombment
<br />❑ Rernawal [] other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />October 3, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street. Grand Island. Nebraska
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />ai
<br />fs.
<br />CAUSE OF DEATH (See instructions and examples)
<br />ta. PART I. Enter the chain ofsveins- diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest.
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a dna: Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Complications Of Advanced Alzheimers Dementia
<br />disease or condition resulting
<br />s
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sewer:daily fist cr,md:tio,u., it b)
<br />any, tending to the cause bated%
<br />/Iran
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />1 Year
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that indtfatact;.
<br />the events resulting in death):_.
<br />LAST
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Hypertension, Chronic Kidney Disease
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />❑ Pregnant at Cme of death
<br />0 Not pregnant, but pregnant wihln 42 days of death
<br />0 Not pregnant but pregnant 43 days to 1 year before death
<br />0 Unknown H pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />0 YES ❑ NO
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />0 Otter (Specify)
<br />onset to death'
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />1 YES ❑ NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO.
<br />3
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October i, 2019
<br />.23b. uR" i 13,4;431 (J /'., Day, v..;
<br />October 2. 2019
<br />CITY/TOWN
<br />23n. "MAE CFDErTM
<br />08:14 AM
<br />23d. To the hist of my knowledge, death occurred at the tine, date and place
<br />and due to the cause(.) stated. (Signature and Tante)
<br />Jennifer C. Harney, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, V.)
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and pap and due to the causes) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 1 NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a Is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jennifer C. Harney, MD, 609 0 Street, Aurora, Nebraska, 68818;
<br />I284. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR(Mo.,Day, Yr.)
<br />October 4, 2019
<br />1
<br />01
<br />OD
<br />
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