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<br />WHEN " THIS I'"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 />9/1/2020
<br />LINCOLN, NEBRASKA
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<br />20200895
<br />SARAH BOHNENKAMP f
<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 />Rodney Dee Johnson
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7_ SOCIAL SECURITY NUMBER
<br />506-20-4412
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Veterans Affairs. Medical Center
<br />8c. CITY OR TOWN OF DEATH (include Zip Code)
<br />Grand tsiand 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />519 West 13th Street I'
<br />N. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11, FATHER'S -NAME (First, Middle, Last, suffix)
<br />Albert Johnson
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) Yes 02/25/1944-05/01/1946
<br />15. METHOD OF DISPOSITION
<br />0 Bursar 0 Donation
<br />® Cremation 0 Entombment
<br />0 Removal 0 Other(Specify)
<br />55. AGE- Last Birthday
<br />(Yrs.)
<br />94
<br />8b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 121 Inpatient
<br />0 ER/Ou patient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />20 11318
<br />3. DATE OF DEATH(Mp. Day,Yr,)
<br />August 16, 2020
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />December 11, 1925
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />6e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />[ Hospice Facility
<br />9g INSIDE CITY LIMITS
<br />IA YES ❑ N
<br />lab. NAME OF SPOUSE (First. < Middle, Last, Suffix) If wife, give maiden name
<br />Colleen Wheeler
<br />f12. MOTHER'S -NAME (First,
<br />Ruth- Whitt
<br />14a. INFORMANT -NAME
<br />Colleen Johnson
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />16b. LICENSE NO.
<br />Middle, Malden Surname)
<br />CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Horne, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See nstructins and examples)
<br />14. 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 />al Aspiration Pneumonia
<br />IMMEDIATE CAUSE (Final
<br />disease or condition: resulting
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b) Dementia
<br />any, leading to the cause gated
<br />on line a.
<br />Enter ills UNDERLYINO CAUSE.
<br />(disease orinjury that. 'Militia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16c. DATE (Mo., Day, Yr.)
<br />August 18, 2020
<br />Nebraska
<br />17b. Zip Cada
<br />68801''
<br />APPROXIMATE INTERVAL
<br />onset to death :.
<br />2 Days
<br />onset to death
<br />> 1 Yr
<br />onset to:death>:
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />18. PART IL OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />Arteriosclerosis, Atrial Fibrillation
<br />onset to death
<br />19, WAS MEDICAL ;EXAMINER
<br />OR CORONER CONTACTEM.
<br />❑ YES ®NO
<br />20, IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant N tkae of death
<br />❑ Noi pregnant, but pregnant 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 />22s. DATE OF INJURY (Mo, t5ay, Yr.)
<br />21a. MANNER OF DEATH:.
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ 00mb/tg Inveettgation
<br />❑ Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFQRMED?;.
<br />❑ YES &J NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABL
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />OYES ❑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 16, 2020
<br />CITY/TOWN;.
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23e. TIME OF DEATH
<br />Auciust 18, 2020 08:50 PM
<br />23d, To tits teat of my knowledge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature end Title)
<br />Jennifer King, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />El YES E NO 0 PROBABLY 0 UNKNOWN
<br />27. NAME, TITLBAND ADORES OF CERTIFIER (Type or Print
<br />Jennifer King, MD, 2201 N Broadwell Ave, Grand Island, Nebraska, 68803
<br />STATE 21p''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 b8,818 Of examination and/or investige ion, in my opinion death ocsorrtd at
<br />the tine, date and piece and due to the causes) stated. (Signature and Tate)
<br />26a. HAS ORGAN OR TISSUE DONATION: BEEN CONSIDERED?
<br />❑ YES NO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a Is NO ❑ YES ❑ NO
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />August 27, 2020
<br />
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