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Mtt6kr" `� Stt$ tmai )n t ° glE!'1''91 M+'cyCi�yp�yy'rr cl4N/yAVtygtNT ;td; ,tom. ..: x ,rr> t9IXt44tttSAt%yAf;,'�" Wffl 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 IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 2/5/2018 LINCOLN, NEBRASKA 20190685' STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENTS -NAME (First, Middle, Last, Suffix) JoAnn E Eickhoff 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) January 23, 2018 &CITY'rAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Se. AGE Last Birthday (Yrs.) Tamov, Nebraska 75 513. UNDER 1 YEAR 5c. UNDER 1 DAY MOS. DAYS HOURS MINS. 6. DATE OF BIRTH (MO., Day, Yr.), February 4, 1942 7. SOCIAL SECURITY NUMBER 506-54-9200 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis ce 8c. CITY OR TOWN OF DEATH (Include Zip Code) o Grand Island 68803 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ERtOutpatient ❑ DOA OTHER 0 Nursing Home/LTC 0 Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 0 Hospice Facility g 9a. RESIDENCE.STATE Nebraska LL 9d. STREET AND NUMBER 4039 Patchwork PI d 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married t 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown 9b. COUNTY Hall 11. FATHER'S -NAME (First, Middle, Last, Suffix) Theophilo Rosenthal 9C. CITY OR TOWN Grand Island 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS` ® YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Ramon L Eickhoff 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Monica Barnes E 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 13 (Yes, Net, or Unk.) No 14a. INFORMANT -NAME Ramon L Eickhoff 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION o ❑ Burial 0 Donation Cremation 0 Entombment ❑Rettlovai 0Other;Specify) 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo;, Day, Yr.) January 26, 2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Westlawn Memorial Park Crematory Grand Island STATE Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livingston -Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska 17b. Zip Code 68803 CAUSE OF DEATH (See instructions and examples) I. PART I. Enter theaChain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arra.►, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only, one cause on a line, Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Cardiac Arrest disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list condition, if b) Respiratory Failure any, Leading to that rause fated on lin a. Enter the UNDERLYING CAUSE (disease or Injury then initiated. the events remitting in death) LAST APPROXIMATE INTERVAL onset to death 1 Day onset to death 1 Day', DUE TO, OR AS A CONSEQUENCE OF: c) Emphysema Exacerbation DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 1 Day onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I. 11/ tit 20. IF FEMALE; ® Not pregnant within past year W 1❑- Pregnant at time of death i0 Not pregnant, but pregnant within 42 days of death ❑Not piwgnant, tial 1ltagnant.'43 days to 1 year before death ❑ Unknown if pregnant within the past year E 22a. DATE OF INJURY (Mo., Day, Yr.) O A 21a. MANNER OF DEATH El Natural 0 Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY 0 Driver/Operator ❑ Passenger 0 Pedestrian Other (Specify) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES J NO 21c. WAS AN AUTOPSY PERFORMED? ❑YES ®NO 21d. WERE AUTOPSY FINDINGS AVAILA TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? OYES NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) January 23,'2018 23b. DATE SIGNED (Mo., Day, Yr.) Janua 26 2018 24b. TIME CF DE.ATN 23c. TIME OF DEATH 09:24 PM 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) Isaacs,. Berp, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES 0 NO 0 PROBABLY ❑ UNKNOWN 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD 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) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES ElNO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO 0 YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803 Aciviveif 28a, REGISTRARS SIGNATURE AO- coir- oNiok 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) r: January 31, 2018 cD N CO CO CT1 ' F*"a