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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 OF ISSUANCE
<br />7/7/2020
<br />LINCOLN, NEBRASKA
<br />202006254
<br />it.-ilket e› -
<br />l; .
<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 08385
<br />1. DECEDENTS?NAME (First, Middle, Last, Suffix)
<br />Jimmy Alan Friedrichsen
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr,)
<br />June 18, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />63
<br />5b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Y)
<br />November 22, 1956
<br />,ra
<br />8b. FACILITY -NAME (If riot Institution, give street and number)
<br />7. SOCIAL SECURITY NUMBER
<br />507-74-5772
<br />CHI Health St. Francis
<br />8a. PLACE OF DEATH
<br />HOSPITAL ©:Inpatient
<br />❑ ER/Ou patient
<br />❑ DOA
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />Hospice Facility
<br />8C. CITY OR TOWN OF DEATH (include Zip Code)
<br />Grants Island 68803
<br />9a. RESrDENCESTATE ,
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9d. STREET AND NUMBER
<br />1223 N. Geddes Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g, INSIDE CITY LIMITS
<br />YES ❑ NO
<br />lOs. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name I'
<br />Vickie Lynne Henrichs
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Melvin Roy Friedichsen
<br />112. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Mary Eleanor Miller
<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 />Vickie Lynne Friednchsen
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />®:Burial ❑Donation
<br />QCremation : a Entombment
<br />QRemoval 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Kelley D Sheridan
<br />16b. LICENSE NO.
<br />1439
<br />16c. DATE (Mo., Day, Yr.)
<br />June 26, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />CITY / TOWN
<br />Cameron Cemetery Wood River
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Livingston-Sondertnann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />17b68803. Zipode
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Respiratory Failure
<br />IMMEoIATS CAVGE (Final
<br />disepse Orcendaion resulting:,
<br />in deathl
<br />Sequentially list conditions, It
<br />any, leading to the cause listed
<br />on linea.
<br />Enterthe EN1DERLYINGCAUSE
<br />(dlaesae or injurythat Instated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Acute Myelogenous Leukemia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART e. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />20. IF FEMALE:
<br />a pregnahtvnthin•past year
<br />pregeent
<br />4004,0::4a4
<br />❑ Net pregnaidi but pragrlent within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown U pregnant within the pest year
<br />2a,: DATE OF INJURY (MO. Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />2 Days
<br />onset to death
<br />3 Months
<br />onset to death
<br />onset to death
<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 0 N
<br />22c. PLACE', OF INJURY -At home, fat'm, street, factory, office building, construction site, etc. (Spectl
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22t', LOCATION OF INJURY'. STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 18, 2020
<br />CITY/TOWN"
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />June 24, 2020 02:20 PM
<br />tad. To the oast of my knowledge, death occurred at the time, date and place
<br />and due to the cause(a) stated. (Signature and Title)
<br />Isaac J. Berg, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES J NO 0 PROBABLY 0 UNKNOWN
<br />STATE ZIP CODE
<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 of examination and/or investigation, in my opinion death occurred et
<br />the bma,' date and place and due to the cause(s) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES 161 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATUREO�Z
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO 0 YES ❑ NO.
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 30, 2020
<br />
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