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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 />DATE OF ISSUANCE
<br />2/18/2020
<br />LINCOLN, NEBRASKA
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<br />ASSISTANT STATE GISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Theresa Eileen Dusatko
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Omaha, Nebraska
<br />7. SOCIAL. SECURITY NUMBER
<br />506-70-1906
<br />8a. AGE - Last Birthday
<br />(Yrs.)
<br />59
<br />lib.`FACILITY-NAME (If not Institution, give street and number)
<br />Hospice House
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 68124
<br />Ba RESIDENCE -STATE
<br />Nebraska
<br />Bd, STREET AND NUMBER
<br />316 N 4th Street
<br />Bb. COUNTY
<br />Hall
<br />Bb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL p Inpatient
<br />Q ER/Outpatient
<br />❑ DOA
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />9c. CITY OR TOWN
<br />Doniphan
<br />HOURS
<br />MINS.
<br />20 01624
<br />3. DATE OF DEATH (Mo„ Day, Yr.)
<br />February 1, 2020
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />August 29, 1960
<br />OTHER 0 Nursing HomeILTC
<br />❑ Decedent's Homs
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />11 Douglas
<br />Be. APT. NO.
<br />Sf. ZIP CODE
<br />68832rgi
<br />f Hospice
<br />fia..JNsIDE CI TYUNITS
<br />YES ONO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden nares*'
<br />Doran Dusatko
<br />11. FATHER'S AME (First, Middle, Last, Suffix)
<br />James Dugan
<br />112.MOTI4ER'S-NAME (First, Middle,
<br />Jeanne Petersen
<br />Maiden Surname)
<br />13. EVER IN U.B. ARMED FORCES? Give dates of service It Yes.
<br />(Ye., No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Doran Dusatko
<br />15. METHOD OF DISPOSITION
<br />Burial Donseon
<br />O Cremation Entombment
<br />Removal 0 Other (Specify)
<br />18a. EMBALMER -SIGNATURE
<br />Katie M. Smydra
<br />18b. UCENSE NO.
<br />1454
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />18a DATE (Mo., Day. Yr.)
<br />February 10. 2020
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />St. Patrick's Cemetery
<br />CITY / TOWN
<br />Hastings
<br />STATE
<br />Nebraska
<br />17a,:FUNERAL. :HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State)
<br />Ali Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />lib. 73P Code
<br />68801
<br />CAUSE OF DEATH (See instrt
<br />oils and examples)
<br />U. PART I. Enter the chain of events- -diseases, Injuries, or compllcatbna.hat 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 one line. Add additional lints If necessary.
<br />IMMEDIATE CAUSE:
<br />BIMEOIATECRUSE "Mel a) Glioblastoma With Unknown Metastasis
<br />Maims* or swolledn ossuRine
<br />In death)"
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially Net conditions, N b)
<br />any, leading to the cause gated
<br />on Nae a.
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />26 Months
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />EnbrsitusoBRLYINGCAUSE C)
<br />Ramo. or cow, nut inhutea
<br />the events racking M death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />onset to death
<br />18. PART IL OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not menden In the underlying cause given In PART L
<br />Seizures
<br />1s. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20.�IF1FEMALE:
<br />4a! Not Imamrit within pest year
<br />© PrepnamatSine ofdeath
<br />.
<br />0 seat Pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days tot year before death
<br />Q: Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />IE Natural Homicide
<br />❑ Accident ❑ Pending invoaaprlon
<br />0 SW1.ide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Or/mi./Operator
<br />-_Q Passenger
<br />©"eedeetnan
<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 />2211. DATE OF INJURY (Mb, 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 AT WORK?
<br />❑YES, 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f LOCATION' OF INJURY STREET & NUMBER APT.NO. CITYITOWN
<br />E
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 1, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />February 6, 2020 08:12 PM
<br />tId. To the best of my knowledge, death occurred at the the, date and place
<br />and due to 11* cause(s) stated. (Signature and Tin)
<br />Erin Dahlke, DO
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO ❑ PROBABLY 0 UNKNOWN
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />74e. On the hula of examination andlor Investigation, In my opinion deett dccurrsd ad
<br />>:tM
<br />On*, date and piece and due to the cause(s) stated. (Signature ane Yitie)
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES 10140
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a Is NO ❑ YES.
<br />0 N
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Erin Dahlke, DO,12565 West Center Rd Suite 100, Omaha, Nebraska, 68144
<br />28a. REGISTRAR'S SIGNATURE
<br />oceS-
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 11, 2020
<br />O
<br />CrN
<br />CD
<br />N
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