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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 iA 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 />12/3/2018
<br />LINCOLN, NEBRASKA
<br />202007832
<br />RUSSELL FOSLER
<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 />Helen VerEtta Johnson
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Greeley, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506-42-2789
<br />o *b. FACILITY -NAME (If not Institution, give street and number)
<br />4!f
<br />CHI Health St. Francis
<br />.c
<br />6a. AGE -Last Birthday
<br />(Yrs.)
<br />79
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />ER/Outpatient
<br />D DOA
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November 8, 2018
<br />6. DATE OF BIRTH (Mo., DIY, Yr.)
<br />June 12, 1939
<br />OTHER ❑ Nursing Home/LTC
<br />❑ Decedent's Home
<br />[f
<br />Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STA
<br />Nebraska
<br />E
<br />9b. COUNTY
<br />Hall
<br />9c. ciTY OR TOWN
<br />Grand Island
<br />8d. COUNTY OF DEATH
<br />Hall
<br />4'
<br />9d. STREET AND NUMBER
<br />418 Stagecoach Rd
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />19a. MARITAL STATUS AT TIME OF DEATH g1 Married 0 Never Married
<br />0 Married, but separated ; 0 Widowed 0 Divorced 0 Unknown
<br />1Ob. NAME OF SPOUSE (FIrst, Middle, Last, Suffix) If wife, give maiden name
<br />Harvey Johnson
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />James Berryman
<br />1 12. MOTHER'S -NAME (First, Middle,
<br />Ella Luethje
<br />Malden Sumame)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk) No
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />® Cremation 0 Entombment
<br />❑ Removal 0 Qther(Specify)
<br />14a. INFORMANT -NAME
<br />Harvey Johnson
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />isa. LICENSE NO.
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Da), Yr.)
<br />November 13, 2018
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Crematory Grand Island
<br />STATE
<br />Nebraska
<br />0
<br />c
<br />tv
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Livingston -Sondermann Funeral Home. 601 N. Webb Road, Grand Island. Nebraska
<br />17b, 2:Code
<br />68803
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death, DO NOTenter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Eater only one cause on a ma. Add additional links H necessary.
<br />IMMEDIATE CAUSE:
<br />^w- %OU4VG1
<br />..5.ass or condition resuitint.
<br />71' e.ee?h)
<br />Sequentially fist conditions, x
<br />any, leading lathe cause listed
<br />on line a
<br />Enter the UNDERLYING CAUSE
<br />Wisest** or injury that Initiated
<br />the events resulting: 4n death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Postprocedure Lung Biopsy, Adenocarcinoma Invasive
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />APPROXIMATE: INTERVAL
<br />onset to death
<br />onset to death
<br />onset to death'
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Coronary Artery Disease, Ischemic Cardiomyopathy, Peripheral Vascular Disease, Hyperlipidemla, History Of Breast Cancer,
<br />History Of Lung Cancer, Chronic Obstructive Lung Disease, Mild Memory Loss
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />0 Pregnant at time of death
<br />0 Not PM/tient, DU( pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown U pregnant within the past year
<br />21a. MANNER OF DEATH
<br />Natural ❑ Honlitide
<br />❑ Accident ❑ Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<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 />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />1
<br />13
<br />ti
<br />Zi.- 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />N
<br />c3 _
<br />23a. DA'T'E OF DEATH (Mo., Day, Yr.)
<br />Zi W November 8 2018
<br />r i rc } 23b. DATE SI'Yi ED 01o., Day, W.) 123.:. TIME OF DEATH
<br />«_ LI, ,,-, J : ,,,,i
<br />0 ` 0 23d. To the best of myknowledge, death occurred at the time, date and place
<br />Ice 8 is'
<br />E W
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />CITY/TOWN
<br />1
<br />and due to the cause(s) stated. (Signature and Title)
<br />Jane A, MIDtnald, MD
<br />5. DID TOAACCO USECONTRIBUTE TO THE DEATH?
<br />® YES 0 NO 0 PROBABLY 0 UNKNOWN
<br />STATE
<br />24s. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />IBX
<br />E. 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD
<br />�+
<br />ty z 24e. On the basis of examination and/or Investigation, In my opinion death occurred et
<br />p the time, date and place and due to the causes) stated. (Signature and Title)
<br />re
<br />o
<br />ZIP CODE
<br />26a. HAS ORGAN OR TISSUE ''<DONATION 8EEN'CONSIDERED?
<br />YES
<br />IX�NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jade A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />8a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED? :s
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />28b. DATE FILED BY REGISTRAR
<br />November 19, 2018
<br />
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