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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 />a/tich 41.444 SARAH BOHNENKAMP f
<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 />DATE OF ISSUANCE
<br />2/3/2020
<br />LINCOLN, NEBRASKA
<br />202001413
<br />1. DECEDENT'S•NAME (First, Middle, Leat, Suffix)
<br />Sandra Jean Rock
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506-60-6645
<br />5a. AGE - Last Birthday,
<br />(Yrs.)
<br />70
<br />8b. FACILITY-NAME(1f not Institution, give street and number)
<br />CHI Health St. Francis
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 24, 2020
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />August 21, 1949
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient OTHER 0 Nursing Home/LTC
<br />❑<ER/Outpatient ❑ Decedent's Home
<br />❑'DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) I8d. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />❑ Hospice Facility
<br />9d STREET AND NUMBER
<br />371 N. Broadwell Avenue
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g INSIDE CITY' LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />Married, but separated 0 Widowed ® Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />11. FATHER'S -NAME
<br />John Rock
<br />Fist, Middle, Last, Suffix)
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Kathryn Donovan
<br />13. EVER IN U.S. ARMED FORCES?
<br />(Yes, No. or WOO No
<br />Give dates of service H Yes.
<br />14a. INFORMANT -NAME
<br />William Werner
<br />15.METHOD OFDISPOSrtPON
<br />❑ Burial 0 Donation
<br />® Cremation ❑ Entombment
<br />❑ Removat :; ❑ OtHr (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />6b. LICENSE NO.
<br />14b. RELATIONSHIP TO DECEDENT
<br />Significant Other
<br />16e. DATE (Ma, Day, Yr.)
<br />January 27, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY /TOWN
<br />Gibbon
<br />STATE.
<br />Nebraska
<br />u
<br />w
<br />5.
<br />1
<br />0
<br />1
<br />X
<br />5
<br />i Q
<br />as
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel. 3005 S. Locust St., Grand Island. Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH(Seeinstructions and examples)
<br />1e. PART L Enter the engine events -diseases, Injuries, or complications -that directly ranted tfht death. DO NOT War temiIna) events such as cardiac arrest,
<br />respiratory arrest, or vent fiCular tbdeation without showing the etiology. DO NOT ABBREVIATE. Ether only one cause on s One. Add additional lines a necessary.
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />in death)
<br />S equally Ildt COnditlons, N s
<br />any. leaping to the Cauca HOW'
<br />on line a
<br />Enter the UNDERLYING CAUSE
<br />. (diaease or .injury.':tat•1015t
<br />ed
<br />hawmsresulting mdah)
<br />LAS? •
<br />IMMEDIATE CAUSE:
<br />a) Respiratory Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Perinephric Abscess
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />c) Radiation From Endometrial Carcinoma
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />> 1 Day
<br />onset to del th
<br />> 1 Week
<br />onset to death
<br />> 1 Year
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />d)
<br />onset di 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 />Severe Protein Calorie Malnutrition, Stage 4 Kidney Disease
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®'NO
<br />20.. IF FEMALE
<br />Not pregnant:within past year
<br />0 Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days or death
<br />0 Not pregnaru but pragdatlt 13 days to 1 year before Wath
<br />❑Unknewn (tpragdddtwltbin the pest year
<br />21a. MANNER OF DEATH
<br />M Natural 0 Homicide
<br />0 Accident 0 Pending investigation
<br />0 Suicide
<br />© coma not no determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑ Pusenger
<br />0 Peesstdan
<br />❑ Other (Specify)
<br />21e. 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, faun, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 24, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 27 2020
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />10:12 AM
<br />tad. To the best of my knowledge, death occurred at the time, data and place
<br />and due to the causes) stated. (Signature and Title)
<br />Jennifer L. Brown, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />STATE ZIP CODE
<br />24a, DATE SIGNED (Mo., Day, Yr.)
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH ..
<br />24d. TIME PRONOUNCED DEAD
<br />24a. On the basis or examination and/or investiga ion, M my opinion Wath occurred at
<br />the time. date and place and due to the cause(s) stated. (Signature and Title)
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a la NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a REGISTRAR'S SIGNATURE
<br />1.100
<br />28b. DATE FILED BY REGISTRAR(Mo.; Day. Yr.) I
<br />January 30, 2020
<br />
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