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<br />WHEN THIS t'' 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 />3/2512019
<br />LINCOLN, NEBRASKA
<br />w
<br />.0
<br />io
<br />Pursuant to
<br />202002569
<br />RUSSELL FOSLER
<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 />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Deborah Ann Bergman
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-88-8870
<br />8b. FACILITY -NAME (HICK Institution, give street and number)
<br />1410 Geddes Street
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />Sa. AGE - Last Birthday
<br />(Yrs.)
<br />59
<br />fib. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />O ER/outpatient
<br />D DOA
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />March 14, 2019
<br />6. DATE OF BIRTH (Mo., Day, Yr,)
<br />June 21, 1959
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other(Speciry)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE.STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />8a CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1410 Geddes Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY' LIMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Marded 0 Never Married
<br />❑;Married, but separated' 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Daniel Lynn Bergman
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Johnnie Wayne Bruns
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Nancy Ann Harder
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service it Yes.
<br />(Yes, No, or Unit.) ND
<br />14a. INFORMANT -NAME;
<br />Daniel Lynn Bergman
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD or DISPOSITION
<br />❑ Burial ❑ Donation
<br />® Cremation 0 Entombment
<br />❑;Removal © Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />Ob. LICENSE NO.
<br />1397
<br />16c. DATE (Mo., Day, Yr.)
<br />March 20, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />1713, Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructionsand examples)
<br />a. PART 1. Enter the Chain of events- diseases, Injuries, or complications -that directly caused the death. 00 NOT enter terminal events such as cardiac arrest,
<br />respiratory street, orventncu)ar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause oh a line.: Add additional lines H necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Respiratory Failure
<br />disease or condition resulting
<br />in death(
<br />Sequentially /let conditions, if
<br />any, leading to the: cause listed:
<br />on line a
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury that Initiated
<br />the events rete
<br />LAST 3'
<br />/n death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Metastatic Neuroendocrine Tumor
<br />APPROXIMATE)NTERVAL
<br />onset to death
<br />Immediate
<br />onset to death
<br />Months
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Severe Malnutrition
<br />onset to death
<br />Months
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />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 />Patient With Widespread Metastatic Neuroendocrine Tumor. Transitioned To Hospice And Passed Away
<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 />0 Not pregnant, but pmgnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown If pregnant wahin the past year
<br />21a. MANNER OF DEATH
<br />▪ Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />❑ Suicide 0 Could net be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />Othet(Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?:
<br />❑YES ®NO
<br />21d. WERE AUTOPSYFINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH,
<br />0 YES 0 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 8. NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 14, 2019
<br />_ Y 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />0 March 19, 2019 07:49 AM
<br />12 Qy7d. To the best of my knowledge, death occurred at the time, date and place
<br />a and due to the cause(s) stated. (Signature and Title)
<br />Michael A. Donner, MD
<br />CITY/TOWN
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED IMo.. Day. Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<br />24h. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24a. On the basis of examination and/or investigation, M my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES ®NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Michael A. Donner, MD, 729 North Custer Avenue, Grand I
<br />28a. REGISTRAR'S SIGNATURE F ? r
<br />land, Nebraska, 68803
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (Mo„ Day, Yr.)
<br />March 20, 2019
<br />
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