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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 />1/8/2021
<br />LINCOLN, NEBRASKA
<br />2021015'2'L
<br />\' 7
<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 />20 19186
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Alice Mae Elstermeier
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (kW, Day. Yt.)
<br />December 30, 2020
<br />4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Central City, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506-50-0878
<br />5a.`AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY.NAME (If not Institution, give street and number)
<br />Bryan Medical Center East
<br />8c, CITY OR TOWN OF DEATH (Include Zip Code)
<br />Lincoln 68506
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />79
<br />5b, UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />8. DATE OF BIRTH ;(Mo.,"Day, Yr.) ..
<br />July 22, 1941
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Lancaster
<br />Hospice Farctt(ty'
<br />9d. STREET AND NUMBER
<br />4124 Iowa Avenue
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />99. INSIDE CITY LIMITS
<br />I YES ❑ NO
<br />104. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed ❑ Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Norman Burddett Elstermeier
<br />11. FATHER'S.NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Alva Sims
<br />Donald Randall
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME'
<br />Norman Burddett Elstermeier
<br />14b. RELATIONSHIP TO DECEDENT'
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donstion
<br />Cremation 0 Entombment
<br />0 Remove( ' 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />January2, 2021
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events- diseases, injuries, or complicetions4het directly caused the death. DO NOT enter terminal events such es 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 It necessary.
<br />IMMEDIATE CAUSE:
<br />a)Acute Hypoxemic Respiratory Failure
<br />IMMEDIATE CAUSE (final
<br />Matisse or condition resUlling
<br />in death)
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />o Hasa
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury that tnitated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)COVID-19 Pneumonia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />17b. Zip Code.
<br />68801:;
<br />APPROXIMATE INTERVAL
<br />onset to death •
<br />Weeks
<br />onset to death
<br />Weeks
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />18PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Interstitial Lung Disease, Moderate Pulmonary Hypertension, Paroxysmal Atrial Fibrillation, Essential Hypertension
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE:
<br />0 Not pregnant within petit year
<br />0 Pregnant at dine of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ :Unknown 6 pregnant within the past year
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operetor
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />21d. WERE AUTOPSY FINDINGS AVAILA$LE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES D NO
<br />22e, DATE OFtNJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF 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:!LOCA TIONIOF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 30, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 2;:2021
<br />23c. TIME OF DEATH
<br />12:31 PM
<br />tad. To the best otmy knowledge, death occurred at the me, date and place
<br />and due to the causetadOne,
<br />s) en
<br />. (Signature and Title)
<br />Michael A. Furasek, MD
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />PICODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or Investigation, In my opinion death occurred 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 />❑ YES ENO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES
<br />E) No
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Michael A. Furasek, MD, 2300 S 16th, Lincoln, Nebraska, 68502
<br />28a. REGISTRAR'S SIGNATURECRt �, .cn
<br />Lipp
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 4, 2021
<br />( 0
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