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<br />WHEN < THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES ME 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 />•DATE OFISSUANCE
<br />10/1512019
<br />LINCOLN, NEBRASKA
<br />m
<br />9
<br />201907036 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. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Judith Jolene Resh
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (No., Day, Yr.)
<br />October 8, 2019
<br />4: CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-54-4134
<br />5a. AGE Last Birthday
<br />(Yrs.)
<br />77
<br />.YY. FACILITY -NAMES"' not Institution, give street and number)
<br />utw Southlake Village Rehabilitation & Care Center
<br />A 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />X Lincoln 68526
<br />32
<br />c
<br />'a
<br />9a RESIDENCE.STATE
<br />Nebraska
<br />9d. STREET AND'NUMBER
<br />509 A St,
<br />9b. COUNTY
<br />Buffalo
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />Mt
<br />DAYS
<br />8a. PLACE O DEATH
<br />HOSPITAL 0 Inpatient
<br />0 ER/Outpatient
<br />fl DOA
<br />9c. CITY OR TOWN
<br />Shelton
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (
<br />foreDay, Yr.)
<br />December 10, 1941
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home ,1 ,.
<br />❑ Other (Specify)
<br />8d. COUNTY !JF DEATH
<br />Lancaster
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68876
<br />Hospice Facility
<br />9g. INSIDE CITY LIMITS'^
<br />® YES ❑ NO
<br />15a. MARITAL STATUSAT:TIME OF DEATH 0 Married Q Never Married
<br />Q Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />d
<br />m
<br />5
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) I' 12. MOTHERS -NAME (First,
<br />Albert Schmidt
<br />Fern Seery
<br />Middle, Maiden Surname)
<br />13. EVER IN U.S. ARMED: FORCES?
<br />(Yes, No, or Unk.) No
<br />Give dates of service If Yes.
<br />14a. INFORMANT -NAME;:
<br />Gayle Resh
<br />14b. RELATIONSHIP TC) DECEDENT.
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑ Donation
<br />® Cremation 0 Entombment
<br />❑;Removal . ❑ Other (Specify)
<br />163. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />1f)b. LICENSE NO.
<br />16c. DATE (Mo., Day. Yr4
<br />October 9, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />BML Cremation Service
<br />17a. FUNERAL Home NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />§ Butherus-Maser & Love Mortuary. 4040 A Street. Lincoln. Nebraska
<br />n
<br />0
<br />ad
<br />W
<br />v
<br />0
<br />CITY / TOWN
<br />Lincoln
<br />STATE
<br />Nebraska
<br />17b.„ Zip Code
<br />68510
<br />CAUSE OF DEATH (See instructions and examples)
<br />1E. PART 1. Enter War these of events- diseases, injuries, or complications -that directly caused the death, o0 NOT entertsmiinal evens such as cardiac arrest,
<br />tecpketory srtasi, Or Ventricular fibrillation without showing the etiology. DO NOT ABBREV}ATE. Enter only ons cause en a ens. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Cardiac Pulmonary Failure
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />n death)
<br />Sequentially list conditions, Y
<br />any, leading to tbe cause Sated
<br />amine
<br />a.
<br />Enter the UNDERLYING CAUSE
<br />{disellRe Oti jury flet initiated:,,:
<br />the events relaters in death)
<br />LAST!:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Metastatic Lung Cancer
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Minutes
<br />onset to death
<br />Months
<br />onsett') death
<br />5 18. PART IL OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />Metastatic Pancreatic Cancer
<br />E
<br />t
<br />V
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />YES ©NO,
<br />0. IF FEMALE;
<br />❑ Not pregnant within past year
<br />❑ Pregnant at Ole. of death
<br />Mot preanant,hut pregnant within 42 days of death
<br />13 Not pfeanad , but pregnant 43 days to 1 year before death
<br />❑ Unknown N pregnant *Min tire past year
<br />t'2 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />4
<br />MY
<br />a
<br />N
<br />O
<br />8
<br />22d. INJURY AT: WORK?
<br />❑,YES ElNO
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide ❑ could not be dourona4
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />Q other ISpacgY)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAEABI E
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO .
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />224. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />in -
<br />J O
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 8, .2019
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />October 10, 2019 07:15 AM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and ore too* nausete) ernee jtlignature arer4;)
<br />fill S, MCAda'rt, PA
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />s
<br />yy r 24c. PRONOUNCED DEAD (Mo., Day, Yr.)( 24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, In my optelon death °accred at
<br />4414. 1.•.s .01" T.11,14.1 s*Ve& t*ionettes and T?t)e)
<br />r°
<br />V
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />24a. DATE SIGNED (Me., Day, Yr.)
<br />44
<br />24b. TIME OF DEAN
<br />❑YES ®NO
<br />Not Applicable if 26a Is NO ❑ YES Q NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jill S. McAdam, PA, 3900 Pine Lake Rd 5, Lincoln, Nebraska, 68542
<br />28b. DATE FILED BY REGISTRAR(Mo.i;Day, Yr.)
<br />October 15, 2019
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