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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 />4/5/2021
<br />LINCOLN, NEBRASKA
<br />202103009
<br />j /a; t r : ..r� r
<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 />21 04301
<br />E
<br />5s
<br />a)
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Jennie Viola McGaffin
<br />2. SEX
<br />Female
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Page, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />74
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OFDEATH `(Mo., Day, Yr.)
<br />March 26, 2021
<br />6. DATE OF BIRTH (Mo., Day,
<br />7: SOCIAL SECURITY NUMBER
<br />508-74-9412
<br />8b `FACILITY NAME Of not Institution, give street and number)
<br />CHI Health St. Francis
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />0 DOA
<br />July 25, 1946
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />Hospice Facility
<br />8c, CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9d. STREET AND NUMBER
<br />1421 N. Vine
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g.rI�N1SIDE CITY LIMITS
<br />tell YES 0 NO
<br />103MARITAL STATUS AT TIME OF DEATH 0 Married ❑ Never Married
<br />0 Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />1Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Timothy Roger McGaffin
<br />11, FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Earl Harold Strong
<br />13, EVER IN U.S. ARMED FORCES?
<br />(Yes, No, or Unk.) No
<br />Give dates of service if Yes.
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)I
<br />Jennie Hauser
<br />14a. INFORMANT -NAME
<br />Mary Jo Rodenbaugh
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15.r METHOD OF DISPOSITION
<br />0 Burial 0 Donation
<br />511 Cremation 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />March 31, 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 />17b. Zip Code
<br />68801:
<br />ra
<br />CAUSE OF DEATH (See instructions and examples)
<br />16. 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 />a) Respiratory Failure
<br />IMMEDIATE CAUSE !Final
<br />disease or condition moulting'
<br />in death)"
<br />Sequentially Ian conditions, if
<br />any, leading to the cause listed
<br />online a.
<br />Enter the UNDERLYING CAUSE
<br />(dteeese or Injury that initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Septic Shock
<br />APPROXIMATE INTERVAL
<br />onset:to death
<br />Imrnediate
<br />onset to death
<br />Hours
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Cardiogenic Shock
<br />onset to death
<br />Hours .
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)Chronic Systolic Heart Failure
<br />18.PARTH. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Transitioned To Comfort Cares And Died In Hospital
<br />20. IF FEMALE;
<br />55 Not pregnant within pest year
<br />Pregnant at time of Worth
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑;: Unknown N pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />onset to death
<br />Years
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED'?
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES El ND
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO...
<br />d
<br />1
<br />r
<br />'+t
<br />22e. DATE OF INJURY (Me, Dey, 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. LOCATION OFINJURY STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 26, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />March 31:; 2021
<br />23c. TIME OF DEATH
<br />04:48 PM
<br />S 3d, To the boot df aiy knowledge, death occurred at the time, date and place
<br />IME due to the'cause(s) stated. (Signature and Title)
<br />2 Michael A. Donner, MD
<br />a
<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 basis of examination and/or Investigation, in my opinion ewe occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature end Ttda):.
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Michael A. Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />26b. WAS CONSENT GRANTED? ..
<br />Not Applicable if 26a is NO
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 2, 2021
<br />1
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