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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 A
<br />F2 6 2 0 0 1 0 3 8 RUSSELL ASSISTANT STATEE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DATE OF ISSUANCE
<br />1/17/2020
<br />LINCOLN, NEBRASKA
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<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Catherine Mae Reed
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 13, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE Last Birthday
<br />1Yrs )
<br />66
<br />5b. UNDER 1 YEAR
<br />MOS. DAYS
<br />Sc. UNDER 1 DAY
<br />HOURS MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />December 28, 1953
<br />7. SOCIAL SECURITY NUMBER
<br />505-72-4784
<br />8b.;FACILITY-NAME (If not Institution, give street and number)
<br />Grand Island Lakeview Care & Rehabilitation Center
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑: ER/Outpatient
<br />❑ DOA
<br />OTHER RI Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />0 Hospice Facility
<br />8c. CITY OR TOWN OF DEATH (include Zip Code)
<br />Grand Island 68801
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9e CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />113 W 20th St
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g INSIDE CITY' LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL; STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />1tib, NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Richard Jesse Reed
<br />11 FATHER'S NAME (First, Middle, Last, Suffix)
<br />Harry George Paulman
<br />112. MOTHER'S -NAME (First,
<br />Suzanne Ruth Nuss
<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 />Richard Jesse Reed
<br />14b. RELATIONSHIP:TO DECEDENT,:
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />Burial ❑ Donation
<br />❑ Cremation 0 Entombment
<br />[} Removat< 0 Other (Specify)
<br />18a. EMBALMER -SIGNATURE
<br />Matthew T. Myers
<br />1$b. LICENSE NO.
<br />1411
<br />16c. DATE (Mo., Day, Yr.)
<br />January 17, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Livinostart-Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska
<br />1Tb: Zip Code
<br />68803
<br />CAUSE OF DEATH, (See instructions and examples)
<br />1a PART Latter die chain of events- diseases, Injuries, cc compikations-that directly caused the death. DO NOT enter tentinal events such as cardiac arrest,
<br />respiratory infest, or ventricular fibriaation without showing the etiology. DO NOT AESREVIATE. Enter only oty cause on a tine. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Breast Cancer
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In death).,.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially ust:oandalone,: t b)
<br />any, wading to the OWN limed
<br />on line a
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />2 Years
<br />DUE TO, ORAS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />(disasse or Injury that initiated
<br />onset to death
<br />ti"even° resulting In death):.: DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Metastatic Tumor In Brain
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES E NO
<br />20.1f FEMALE:
<br />Not pregnant within past year
<br />0 Pregnant at time of death
<br />Not pregnant, but pregnant within 42 days of death
<br />Not pregnant, but pregnant 43 days to 1 year before death
<br />unknown it preonint within the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide © Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE Of DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d: INJURY AT WORK?
<br />❑YES ❑ NO
<br />22b. TIME OF INJURY
<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 & NUMBER, APT.NO.
<br />23e. DATE OP DEATH (Mo., Day, Yr.)
<br />January 13, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 14.2020
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />10:20 PM
<br />3d. To the beet of my knowledge, death occurred at the tion, date and place
<br />and due to the caue(s) stated. (Signature and Title)
<br />Rebecca Steinke, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY ® UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or inveatiga ion, In my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Tme)
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES ®NO
<br />28b. 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 />Rebecca! Steinke;.: MD, 2116 W Faidley #400, Box 9802, Grand Island,. Nebraska, 68803
<br />I28a.: REGISTRAR'S ', IGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 15, 2020
<br />
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