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<br />@„,; , STATE OF NEBRASKA
<br />�`QCA1A) r t �ty14YP1A0.11 a �a� sAsives .....>: rrr to °.... rrrrrmlrt I1rPu•D7 d ��7y 111 1 �t AlE'� �)J
<br />,1riBlVta, (%rdr6�iaalt�i�l t,ri
<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 , •� /y
<br />DATE OF ISSUANCE
<br />9/4/2019
<br />LINCOLN, NEBRASKA
<br />vammer
<br />202009655 RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT QF 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 />Barbara Louise Elite
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Harlan, Iowa
<br />7. SOCIAL SECURITY NUMBER
<br />485.46-3298
<br />50. AGE - Last Birthday
<br />(YYtt.)
<br />81
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Bryan Medical Center West
<br />80. CITY OR TOWN OF DEATH (include Zip Code)
<br />Lincoln 68502
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />4177 Mason Avenue
<br />ob.couNTY
<br />Hall
<br />iOa. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />u Married, but separated ® Widowed d Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Arnold Johannsen
<br />*8b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />M0$,
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL Inpatient
<br />0 ER/Outpatient
<br />Q D0A
<br />9c. CITY OR TOWN
<br />Grand island
<br />10b. NAME OF SPOU
<br />John EiltS
<br />HOURS
<br />MINS.
<br />n(carr' 41)4lQy1
<br />eyyryr9
<br />.1
<br />�II ti�)t if1155ri 111)11,v,,vltittift o,ari3'
<br />at'laa
<br />�d1''' yt�tP j7j))ir ii „(@�'t5Y/1fr
<br />IBett"ala1
<br />3. DATE OF DEATH (Mo., Day, Yr)
<br />Augugt 20, 2019
<br />8. DATE OF BIRTH (MO`Dayt'
<br />Aupust 5, 1938
<br />OTHER ❑ Nursing Hone/LTC
<br />❑ Decedent's Home
<br />❑ Other (SpacMy)
<br />Sd. COUNTY OF DEATH
<br />Lancaster
<br />9e. APT. NO.
<br />M. ZIP CODE
<br />68801
<br />Q Hospice Facility
<br />20. INSIDE CITY MITIS
<br />(gj YES ❑ N0
<br />(First, Middle, Last, Suffix) If wife, give maiden name
<br />I12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Maxine Koos
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service it Yes.
<br />(Yes, No, or Link.) (40
<br />15. METHOD OF DISPOSITION
<br />0 Burial 0 Donation
<br />® Cremation 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />14a. INFORMANT -NAME
<br />Randy Files
<br />16a. EMBALMER -SIGNATURE
<br />18b. LICENSE NO.
<br />Not Embalmed
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />BML Cremation Service
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Agfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />CITY /TOWN
<br />Lincoln
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />18c. DATE (Mo., Day Yr.)
<br />August 25, 2019
<br />STATE
<br />Nebraska
<br />17b.ZipCode
<br />68801
<br />CAUSE OF DEATH(See lnstruct~lgns anstexamoles)
<br />11. PARI' I. Soler the chitin of menta--dleaasse, injuries, or compllcanonaihat directly cawed the death. 00 NOT enter terminal events such as cardiac arrest,
<br />reeplratery erre**, dr Ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only ono/cause on a 100, Add addblenal llama If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Cerebral Anoxia
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In Math)
<br />secernalally Net 4 sedition, d
<br />any, abiding to the cause bated
<br />on alias a_. _... _.
<br />Enter the UNDERLYING CAUSE
<br />tdlsexe or Injury Met indlettm:
<br />ufhtg m Math)
<br />tile events t'es
<br />LAST
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />b)Respiratory Failure
<br />d
<br />APPROXIR ATEINTERVAIR;
<br />onset to Beads
<br />Hours
<br />onset tn.dS1tlt
<br />Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)Acute Lung Injury
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />d)Blood Transfusion Related Lung Injury
<br />onset to death
<br />Weeks
<br />onset to death'
<br />Weeks
<br />18. PART 11. OTHER SIONIFIC
<br />ANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART 1.
<br />20. IF FEMALE:
<br />❑ Not pregnant within part year
<br />0 Pregnant et dm* of death
<br />❑ No( pregnant. but pregnant wkhln 42 days of death
<br />0 Mot parent, 4114 pregnant 43 days let year before death
<br />❑ Unknown If pregnant wanln the pest year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />1 22d. INJURY ATWORKT
<br />OYES ONO
<br />aV
<br />21a. MANNER OF DEATH
<br />® Natural El Hatfield*
<br />ield*
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide 0 04:vid net be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />Pedestrian
<br />0 Other.1Sp•cify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES 1Rr NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />© YES ® NO
<br />21d. WERE AUTOPSY PtND(NOS AVAILABLE
<br />TO COMPLETE CAUSE O..F 050T117:
<br />@YES ONt?
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, eta (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET A NUMBER, APT.NO.
<br />230. DATE OF DEATH (Mo., Day, Yr.)
<br />August 20, 2019
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />August 30. 2019
<br />CITYITOWN
<br />23c. TIME OF DEATH
<br />08:2Q PM
<br />3d. To the beat of my knowledge, death occurred et the time, date and place
<br />and due to the cause(a) stated. (Signature and Title)
<br />Ted Triggs, DO
<br />Bgr§a
<br />STATE MP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examinedon and/or Investigation, In my opinion death occured at
<br />the time, date and place and due to the cause(*) silted. Nlgnatura and ME
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN 0 YES ® NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Ted Triggs, DO, 2300 S. 16th St., 7th Floor, Lincoln, Nebraska, 68502
<br />28a. REGISTRARS SIGNATURE
<br />. 2..X3sp
<br />28b. WAS CONSENT GRANTED? .>
<br />Not Applicable If 26a Is NO ❑ YES I j NO
<br />28b. DATE FILED BY REGISTRAR(Mo„ Day, Yr.)
<br />August 22, 2019
<br />1
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