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<br />WHEN 'i 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 S RVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />1/27/2020
<br />LINCOLN, NEBRASKA
<br />20200549
<br />O SISTANT 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. DECEDENT'S -NAME ,(First, Middle, Last, Suffix)
<br />Catherine Clara Miller
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508-38-1412
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 18, 2020
<br />8b. FACILITY -NAME (Hoot Institution, give street and number)
<br />CHI Health St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />5a. AGE • Last Birthday
<br />(Yrs4 MOS. DAYS
<br />86 'r
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />0 ERIQutpatient
<br />DOA
<br />5b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />HOURS MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />June 16 1933
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedents Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />0 Hospice Facility
<br />9a. REBIDENCEESTATE >.
<br />Nebraska:
<br />9b. COUNTY
<br />Hall
<br />9e. CITY OR TOWN
<br />Wood River
<br />9d. STREET AND NUMBER
<br />303 West 13th Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />9g. INSIDE CITY' LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Marded 0 Never Married 104. NAME OF SPOUSE (fk;t, Middle, Last, Suffix) N wife, give maiden name
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown Donald Miller
<br />11,1=ATHER'S NAME {First, Middle, Last, Suffix)
<br />William Rief
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Dora Ritter
<br />13. EVER IN U.S, ARMED FORCES? Give dates of service 0 Yes.
<br />{Yes, No, or link,) No
<br />14a. INFORMANT -NAME
<br />Christine Weitzel
<br />m
<br />ex
<br />16. METHOD OF DISPOSITION
<br />E Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />Remove(0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Gwen K. Hyronemus
<br />16b. LICENSE NO.
<br />1448
<br />14b. RELATIONSHIP: TO DECEDENT::
<br />Daughter
<br />16c. DATE (Mo., Day, YT.)
<br />January 22, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />CITY I TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />174. FUNERAL? HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />ADfel Funeral Home, 1123 W. 2nd. Grand Island. Nebraska
<br />17b.;Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />111. PART £ Enler the chain of eve�4lseases, injuries, or complicatlons•thet directly caused Med./M. DO: NOT enter terminal events such es cardiac arrest,
<br />inspiratory wrest, or ventricular fibrillation without showing the etiology. DO NOT A8$REVIATE, Eller *My one cause on a tine. Add addltbnal lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Bowel Perforation
<br />disease or condition resulting
<br />In death) _.
<br />sequentially iltt4ent d:me, It:
<br />any, Medina bathe aces listed
<br />on title a.
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />b) Post Op Ileus
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) Percutaneous Endoscopic Gastrostomy Tube Placement was done for Dysphagia,
<br />(disuse winjurytnstNstutad NrturninQir'
<br />the events restating In death)::: DUE TO, OR AS A CONSEQUENCE OF:
<br />Lear d)Amyotrophic Lateral Sclerosis
<br />APPROXIMATETERVAI.
<br />onset to death
<br />Hours
<br />onset (o death
<br />Hours
<br />onset to death
<br />Months
<br />onset to death
<br />Months
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions 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 E NO
<br />20. IF FEMALE:
<br />0 Not pregnant Within pant year
<br />0 Pregnant at time of death
<br />❑> Net pregnant, but pregnant within 42 days of Wath
<br />❑. Not pregnant, LYE pregnant 42 days to 1 year before death
<br />❑ Unknown* if pregnant w41tn the pan year
<br />21a. MANNER OF DEATH
<br />Natural 0 homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION
<br />❑`DriveNOperator
<br />0 Passenger
<br />0 Pedestrian
<br />© Other(SpecIy)
<br />INJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES E NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />O YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. Haiti AT WORK?
<br />DYES ONO
<br />22b. TIME OF INJURY
<br />22e. 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 />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 18 2020
<br />23b, DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />January 24. 2020 04:38 PM
<br />23d. To the ben of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Tkle)
<br />Susan M. Newman, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES E NO 0 PROBABLY 0 UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, In my opinion death occurred at
<br />the time, dab 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 />Susan M Newman, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable 0 26a Is NO 0 YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 24, 2020
<br />
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