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t1170f3Uoal3$�$1 �3?3rwati3fi9,$S�i�%�at�ra3!.i3k$ 1.19 i by .Y I@ 41114110,01,4 L11r3 14ttiyf�lRit,` 4lttttit ' tiNWAthiCfM�` ,G3t 1)%li1gUF tlfizo WHEN.'I THIS !"COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 12/18/2019 LINCOLN, NEBRASKA 2020020'79 e. RUSSELL FOSLER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Marietta M Hofferber 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) October 23, 2019 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH North Bend, Nebraska 7. SOCIAL SECURITY NUMBER 505-72-2749 5a, AGE- Last Birthday (Yrs.) 67 8b. FACILITY -NAME (if not institution, give street and number) CHI Health St. Francis 3c. C,T' on rCZ. • Th (;,tciade Zip Ctn..) Grand Island 68803 5b. UNDER 1 YEAR 5c. UNDER 1 DAY MOS. DAYS 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/Outpatient ❑ DOA HOURS MINS. 6. DATE OF BIRTH (Ma, Day, Yr.) April 7, 1952 OTHER 0 Nursing Home/LTC ❑ Decedent's Home ❑ Other (Specify) IbdCOUNTY fir °OATH . Hall 0 Hospice Facility 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 2811 Circle Drive 9b. COUNTY Hall 9C. CITY OR TOWN Grand Island 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY UNITS E YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married ❑ Married, but separated 0 Widowed ❑ Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Cyndie Larson 11. FATHER'S -NAME (First, Middle, Last, Suffix) Fred Hofferber Viola Strong I 12. MOTHER'S -NAME (First, Middle, Maiden Surname) 13. EVER IN U.S.; ARMED FORCES? Give dates of service if Yes. (Yes, NO, or Unit) No 14a. INFORMANT -NAME Cyndie Larson 14b. RELATIONSHIP TO DECEDENT. Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation E Cremation 0 Entombment 0 Removal ;❑ Other (Specify) 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) October 24, 2019 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Heafey-Hoffman-Dworak-Cutler Omaha STATE Nebraska 17a. FUNERAL HONE NAME AND MAIUNG ADDRESS (Street, City or Town, State) Curran Funeral Chapel. 3005 S. Locust St.. Grand Island. Nebraska 17b Zip Code 68801 CAUSE OF DEATH See instructionsand examples) IS. PART I. enter the Chain of events- -diseases, injuries, or complications -that direciiy caused the death. DO NOT enter tenpbral events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a tine. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Ventricular Fibrillation Cardiac Arrest disease or condition resulting in daath) Sequentially list conditions, if ay Inodh'p to ti,, cc,+Ili d on line a. Enter the UNDERLYING CAUSE (disegsaeriniurythet initiated: the events resuhidg in death( LAST DUE TO, OR AS A CONSEQUENCE OF: b)Acute On Chronic Hypoxic Respiratory Failure APPROXIMATE INTERVAL. onset to death Immediate onset to death Prior DUE TO, OR AS A CONSEQUENCE OF: c)Acute Renal Failure DUE TO, OR AS A CONSEQUENCE OF: d)Gastrointestinal Bleeding onset to death Prior onset to death Prior S 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Shock Liver, Lactic Acidosis, Severe Sepsis, Community Acquired Pneumonia to 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑YES ®310:: 0. W FEMALE: Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant but pregnant 43 days to 1 year before death ❑ unknown If pregnant within the past year 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation 0 Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY El Dr:er/Operator ❑ Passenger 0 Pedestrian 0 Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH?, ❑ YES ❑ NO „0 22a. DATE OF INJURY (Mo., Day, Yr.) a1 22d, INJURY AT WORK? ❑ YES ❑ NO 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED a 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. N O 7L S C to 7 I' a CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) October 23, 2019 9 23' . DATE SIGNED (Mo., Day, Yr.) I 23c. TIME OF DEATH J z October 28, 2019 I 11:07 PM Q 0 3d. To the best of my knowledge, death occurred at the time, date and piece B c and due to the cause(s) stated. (Signature and Title) g MichaetA. Donner, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES E NO ❑ PROBABLY 0 UNKNOWN 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH g7 t 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD Wz O g U U: 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the taunts) stated. (Signature and Title) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ENO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Michael A. Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28a, REGISTRA R'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 29, 2019 c FP co Q