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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 TRITE 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 ire
<br />DATE OF ISSUANCE RUSSELL FOSLER
<br />202001759
<br />ASSISTANT REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />118/2020
<br />LINCOLN, NEBRASKA
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Alice M Spiehs
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Loup City, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506-28-2376
<br />6a, AGE • Last Birthday
<br />(Yrs.)
<br />92
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Brookefield Park
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />St. Paul 68873
<br />9a. RESIDENCE -STATE
<br />Ntbraska
<br />9d. STREET AND NUMBER
<br />140 S Heritage
<br />Bb. UNDER 1 YEAR
<br />MOS, DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />ER/Outpatient
<br />O DOA
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 1, 2019
<br />6. DATE OF BIRTH (Mo. Day, Yr.).
<br />September 15, 1927
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />0 Hospice Facility
<br />9b. COUNTY
<br />Howard
<br />m
<br />g too. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />❑ Married, but separated: go Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Char M.Cal:He
<br />18d. COUNTY OF DEATH
<br />Howard
<br />ac, Gi1Y oRTOWN
<br />St. Paul
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68873
<br />9g. INSIDE CITY LIMITS"
<br />® YES ❑ NO
<br />10b. NAME QF. SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Kenneth Spiehs
<br />13. EVER IN U.S. ARME) FORCES? Give dates of service If Yes.
<br />(Yes, No, or UnK.) NO
<br />5. METHOD OF;t3ISPOSITION
<br />® Burial © Donation
<br />o Cremation 0 Entombment
<br />[Removal [] other'(Specify)
<br />12. MQTHERIS-NAME (First, Middle,
<br />) vwwfic:
<br />14a. INFORMANT -NAME
<br />Rex Spiehs
<br />16a. EMBALMER -SIGNATURE
<br />Matthew T. Myers
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />16b. LICENSE NO.
<br />1411
<br />CITY / TOWN
<br />Westlawn Memorial Park Cemetery Grand Island
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Livingston -Sondermann Funeral Home. 601 N. Webb Road. Grand Island, Nebraska
<br />0
<br />m
<br />CAUSE OF DEATH (See instructions, and examples)
<br />Maiden Surname)
<br />14. PART I. Enter the chain of events- -diseases, injuries, or complications4hat directly caused the death -00 NOT enter terminal evanta such as cardiac arrest,
<br />respiratory arrest, or ventricular fibriaation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause an a tine, Add additional lines N necessary.
<br />IMMEDIATE CAUSE:
<br />a) Respiratory Failure
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />m death)
<br />Sequentially Ilet conditions, If
<br />S any, INdin9 to the Cause listed:
<br />y on line
<br />m
<br />5 Enter the UNDERLYING CAUSE
<br />(disease or Injury -that initiated
<br />0
<br />s
<br />d
<br />the events resulting in death)
<br />LAST'
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Unknown Cause
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />16c. DATE (Mo., Day, Yr.)
<br />December 5, 2019
<br />STATE
<br />Nebraska
<br />17b.zip Code
<br />68803
<br />APPROXIMATE'INTERVAt.
<br />onset to death
<br />2 Days
<br />onset
<br />fit lE TO. OR AS F. CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to dbath
<br />5 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />Alzheimer's Dementia
<br />en
<br />t• 0. IF FEMALE:
<br />0 Not pregnant within past year
<br />_
<br />v 0
<br />Pregnant at time of death
<br />❑ Not pregnant, but Pregnant within 42 days of death
<br />.V D Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ unknown it pmgnant within the past year
<br />,Q 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />A
<br />Zr.
<br />N
<br />0
<br />0,,
<br />0
<br />22d. INJURY AT WORK?
<br />QYES QNO
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident 0 Pending Investigation
<br />O Suicide 0 Could' not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />0 Other :(Speci y)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<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 />22b. TIME OF INJURY 122c. 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 />)
<br />a
<br />e
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December. 2019
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />January 7, 2020 03:15 AM
<br />3d. To the best of my knowledge, death occurred at the tkne, date and place
<br />and due to the cause(s) stated. (Signature and Tide)
<br />Chris Tomhave, MD
<br />CITY/TOWN
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO ❑ PROBABLY 0 UNKNOWN
<br />STATE
<br />Z > 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />rgE
<br />va>. 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />a
<br />Fq
<br />W 2
<br />eN
<br />p
<br />ZIP CODE
<br />24e. On the basis of examination and/or investigation, In my opinion death occurred at
<br />the time, data and place and due to the cause(s) stated. (Signature and Tale)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES E] NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Chris Tornhave, MD, 1113 Sherman, St. Paul, Nebraska, 68873
<br />28a. REGISTRARS SIGNATURE i_ rrr7
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 7, 2020
<br />
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