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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 />8/11/2020
<br />LINCOLN, NEBRASKA
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<br />202006843
<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 />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Dorothy G Aubushon
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Rockville, Nebraska
<br />7, SOCIAL SECURITY
<br />50642-4536
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />81
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />6c. UNDER I DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />20 10140
<br />3. DATE OF DEATH (Mo.,Day, Yr.)
<br />August 2, 2020
<br />6. DATE OF BIRTH (Mo.; Day, Yr.)
<br />August 7, 1938
<br />NUMBER
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Good Samaritan Society -Grand Island Village
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />OTHER ® Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />0 Hospice Facility
<br />9d, STREET AND NUMBER
<br />3921 Reuting Road
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />2 YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Chuck Aubushon
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 112. MOTHER'S -NAME (First,
<br />Elizabeth Barent
<br />Stanley Raschynialski
<br />Middle, Maiden Surname)
<br />13. EVER IN US. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Chuck Aubushon
<br />14b. RELATIONSHIP TO oecznafiT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />Cremation ❑ Entombment
<br />❑'Removal ' ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />August 3 202
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY / TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />lie. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfet Funeral Home, 1123 W. 2nd, Grand Island. Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />1a. 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. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Endometrial Cancer
<br />IMMEDIATE CAUSE (Final
<br />disease Of condition resuxirlg
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, If b)
<br />any, lading tq the cause; bated
<br />on line a,
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(dise*se or injury that initiated
<br />the events resulting in death)
<br />LAST
<br />17b. Zip Code:.:
<br />68801 s.
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />N/a,
<br />onset to death
<br />onset to death `.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />10.'PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />19. WAS MEDICAL EIfAMINER
<br />OR CORONER CONTACTED? •
<br />® YES ❑ NO
<br />20. IF FEMALE:
<br />©` Not pregnant within past, year
<br />❑. Pregnant at time of death'
<br />0 Not pregnant, but prepnaot within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />❑ YES II 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, etc, (Speaty)
<br />22d. INJURY AT WORK?
<br />❑ YES :❑ No.
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f, LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODS
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 2, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />August 5, 2020
<br />23c. TIME OF DEATH
<br />02:17 AM
<br />28d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Jennifer A Murray. FNP
<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 />244.On the basis of examination and/or investigation, in my opinion deathoccuffed at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title).'
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ❑ NO (❑ PROBABLY ® UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />OYES NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YES'
<br />❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jennifer A Murray, FNP, 3016 W Faidley, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE 3
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 5, 2020
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