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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 OFISSUANCE
<br />4/13/2020
<br />LINCOLN, NEBRASKA
<br />202002816
<br />.�rrj2 j
<br />SARAH BOHNENKAMP
<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 />20 04418
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Theresa :Marie Clausen
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 1, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Carroll, Iowa
<br />7. SO IAL SECURITY NUMBER
<br />470.72-6785
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />63
<br />O
<br />m
<br />E
<br />u
<br />0
<br />a
<br />,b irACILITf 1vAIHE (tr ftot institution, give street end number)
<br />CHI Health Bergan Mercy
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day,. Yr.)
<br />February 21, 1957
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑
<br />Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)8d. COUNTY OF DEATH
<br />Omaha 69124 I Douglas
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />© kloapice Facility
<br />9d. STREET AND NUMBER
<br />423 Ponderosa Drive
<br />Be. APT. NO.
<br />91. ZIP CODE
<br />68803
<br />N. INSIDE CITY LIMIT$
<br />® YEs ❑
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Curt Clausen
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Sumame)
<br />Cletus Hein Lola Oswald
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Curt Clausen
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑ Buns' 0 Donation
<br />Ej Cremation ❑ Entombment
<br />Removat ` ❑ Other (Spedfy)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />April 3. 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Heafey-Hoffman-Dworak-Cutler Omaha
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123.W. 2nd, Grand Island, Nebraska
<br />17b. Zlp Code
<br />68801
<br />CAUSE OF DEATH (See Instructions and examples)
<br />13. PART L Enter the chain of events- 4tsasses, Mjurles, or complicationa.that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory wrest, or ventricular Iterillation without showing tits etiology. DO NOT ABBREVIATE. Enter only one Cause on a line. Add additional lines H necessary.
<br />IMMEDIATE CAUSE:
<br />a)Cardiorespiratory Failure
<br />IMMEDIATE CAUSE (final
<br />disease or condition resulting
<br />M death)
<br />Sequentially Inst conditions, If
<br />any, leading to. the Cause listed
<br />online a.
<br />Enter tat UNDEReTINID CAUSE
<br />(di{eeae or Injury that Initiated
<br />the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Multiorgan Failure With Acute Respiratory Distress Sydrome
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)Complicated Pneumonia
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Days
<br />onset to death
<br />Days
<br />onset to death
<br />Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />Onset to death
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS-Conditlons contributing to the death but not resulting in the underlying cause given in PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />20. IF FEMALE:
<br />Nat pregnant wMkc pastyear
<br />❑ Pregnantattime w(Matti
<br />O Not predated, but pregnant within 42 days of death
<br />O Not pregnant, but pregnant 43 days to 1 year before death
<br />❑.:; Unknown If pregnant within the peat year
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not M determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<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 />22a; DATE OF INJURY (Mo, Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site,
<br />etc, (Seat
<br />22d. INJURY AT WORK?
<br />• ❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221, 'LOCATION:OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN
<br />eQa
<br />STA IE
<br />:lir! iG68
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 1, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Aunt 2.2020 04:40 PM
<br />23d To the best Only knowledge, death occurred at the dme, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Carrie L. Valenta, MD
<br />26. pm TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />_❑ YES ❑ NO Q PROBABLY ® UNKNOWN
<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 />24e. On the basis 0 examination end/or investigation, In 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 />NAME,11T1-E AND ADDRESS OF CERTIFIER (Type or Print
<br />Carrie L. Valenta, MD, 7500 Mercy Rd, Omaha Nebraska, 68124
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?.
<br />Not Applicable H 28a Is NO 4s VES
<br />N
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 8, 2020
<br />
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