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<br />WHEN T111S "COPY CARRIES THE RAISED SEAL`' OF HS' 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 />8/28/2020
<br />LINCOLN, NEBRASKA
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<br />SARAH BOHNENKAMP f
<br />SSISTANT 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 />k. DECEDENTS•NAME (First, Middle, Last, Suffix)
<br />Ellen Lois Goer)
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Doniphan, Nebraska
<br />T. SOCIAL SECURITY NUMBER
<br />508-32.8290
<br />Sa. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Brookefield Park
<br />8c. CITY OR TOWN OF DEATH, (Include Zip Code)
<br />St. Paut 68873
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />1405 Heritage Drive
<br />9b. COUNTY
<br />Howard
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />❑ Married, but separated 0 Widowed ® Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />William Carl Henry Horst
<br />13. EVER 1N U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />16. METHOD OF DISPOSITION
<br />® Hurts( 0 Donation
<br />❑ Otemat:On ❑ Entombment
<br />❑ Removal ® Other (Specify)
<br />91
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />6c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE QF DEATH
<br />HOSPITAL. ❑ inpatient
<br />❑ ER/Outpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />St. Paul.
<br />HOURS
<br />MINS.
<br />2011105
<br />3. DATE OF DEATH (Mo., Day,
<br />August 22, 2020;
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />February 24,;;1929
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Howard
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68873
<br />❑ Hospice Facility
<br />9g. fl4SIDE CITY LIMITS
<br />® YES •ONO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />f 12. MOTHER'S -NAME (First, Middle,
<br />Emma > Pauline Hamann
<br />14a. INFORMANT -NAME
<br />Barbara S Sack
<br />16a. EMBALMER -SIGNATURE
<br />Todd M Peters
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION'
<br />St. Libory's Catholic Cemetery
<br />17a, FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State);,
<br />Peters Funeral Home, 302 Second Street, PO Box 181, St. Paul, Nebraska
<br />16b. LICENSE NO.
<br />1078
<br />CITY / TOWN
<br />St. Libory
<br />CAUSE OF DEATH Mee tnatructions and examples)
<br />Maiden Sumame)
<br />18. PART I. Einer 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) Respiratory Failure
<br />MEDIATE CAUSE (Final
<br />disease: or conditlOn resulting..
<br />Sequentially list conditions, H
<br />any, leading to the cause listed.
<br />online*.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter Ow UNDERLYING CAUSE C)
<br />(disease or injury that initiated
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Upper Respiratory Infection
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />16c. DATE (Mo., Day, Yr.)
<br />August 26, 2020
<br />STATE
<br />Nebraska
<br />170. Zip Code
<br />68873
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />8 Hours
<br />onset to death
<br />3 Weeks
<br />onset to death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST _. _... d)
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in
<br />History 01 Cerebral Vascular Accident
<br />e underlying cause given in PART 1.
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year'
<br />0 Pregnant at time oY dead!
<br />❑ Not pregnant,. but dbathn within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident ❑ Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21 b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />:❑ Passenger
<br />0 Pedestrian
<br />0 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 />22c. PLACE QP INJURY -At home, farm, street, factory, office building, construction site, etc, (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES ❑NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 22, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />August 24, 2020
<br />CITY/T
<br />23c. TIME OF DEATH
<br />05:38 PM
<br />2d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to iheceueeis) stated. (Signature and Title)
<br />Chris Tomhave, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Vr.)
<br />ZIP CODE
<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 ens, date and place and due to the cause(*) stated. (Signature and MN)
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES El NO ❑,'PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Chris Tomhave, MD, 1113 Sherman, St. Paul, Nebraska, 68873
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES i7 e
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YE
<br />NO
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 24, 2020
<br />1
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