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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 OFISSUANCE
<br />4/13/2020
<br />LINCOLN, NEBRASKA
<br />2021030'8 Amcil
<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 04418
<br />1. DEMENTS -NAME (First, Middle, Last, Suffix)
<br />Theresa 'Marie Clausen
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH'(Mo., Day, Yr.)
<br />April 1, 2024
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Carroll, Iowa
<br />7.:SDC1At. SECURITY NUMBER
<br />470-72-6785
<br />8a. AGE • Leat Birthday
<br />(Yrs.)
<br />63
<br />Ob. LITi-KAME. (IF rein lastittion, give *ir et a nc: nw,nireri
<br />72 CHI Health Bergan Mercy
<br />8c, CITY OR TOWN Of DEATH (Include Zip Code)
<br />Omaha 68124
<br />9
<br />5
<br />9a. RESIDENCE•STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER 1 YEAR
<br />8c. 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 />6. DATE OF BIRTH (Mo., Yr:)
<br />February 21, 1957 _.
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Douglas
<br />❑ Hospice Facility
<br />sd STREET AILD NUMBER
<br />423 Ponderosa Drtve
<br />9s. APT. NO.
<br />W. ZIP CODE
<br />68803
<br />9p. IMIDE CITY LIMITS
<br />C)sl YeS 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH E) Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) H wife, give maiden name
<br />Curt Clausen
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Cletus Hein Lola Oswald
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Curt Clausen
<br />0
<br />v
<br />ar
<br />t
<br />a
<br />tS
<br />16. PART I. Enter the chain of events- slims'., Injuries, or compllcationsthat directly caused the death. DO NOT enter t.mnnal events such u cardiac arrest,
<br />i
<br />•.anl?Tnrry n : x', ••. want-1.40sr«9*ige.ow Wrh..o. ehr!••n .10 efroonty 'M NnT anPDSUTAT5 Sate.er••so nna Ono. Add .ddl k n'' nu* M wicasury
<br />e
<br />a
<br />m
<br />13
<br />a
<br />0
<br />0
<br />0
<br />0
<br />t+I
<br />m
<br />15. METHOD OF DISPOSITION
<br />O Burial ❑Donation
<br />J Cremation 0 Entombment
<br />Removal 0 Other (Spedfy)
<br />16e. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Heafey-Hoffman-Dwora k -Cutler
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Aofel Funeral Horne, 1123 W. 2nd, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Omaha
<br />CAUSE OF DEATH (See instructions and examples)
<br />IMMEDIATE CAUSE:
<br />IMeEDIAmGAusE how a)Cardiorespiratory Failure
<br />Omagh; Condition smarts
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially Oat conditions, if b)Multiorgan Failure With Acute Respiratory Distress Sydrome
<br />any,: loading tothe calmlisted
<br />online * DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter tan UNDERLYING CAUSE
<br />wawa or injurythat Initnted
<br />the events resulting In MOM)
<br />LAST
<br />c)Complicated Pneumonia
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.) ..,
<br />April 3, 2020
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Days
<br />onset to death
<br />Days
<br />onset to death
<br />Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART fi. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART!.
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />20. IF FEMALE:;
<br />®::Not Oradea cerebro paatyar
<br />9 Praaitem OCRing ofdeeth
<br />B' Net pregnant, but pregnant within 42 days or drat
<br />Not pregnant, but pregnsM 43 days to 1 you before Math
<br />❑Unknown ifpregnant within the pat year
<br />224 DATE OF INJURY (Mo., Day, Yr.)
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not in determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 DrtwrlOperator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<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 />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, ata
<br />Spey)
<br />22d. INJURY AT WORK? J22e. DESCRIBE HOW INJURY OCCURRED
<br />❑ YES ❑ NO
<br />22fLOCATION OFINJURY STREET & NUMBER, APT.NO. CITY/TOWN
<br />:
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 1, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23e. TIME OF DEATH
<br />Mai . 2;020 04:40 PM
<br />23d. TO.ihs 46t of my knowledge, Math occurred at the time, date and place
<br />611d are todte'cause(s) stated. (Signature and Titin)
<br />Carrie L. Valenta, MD
<br />STATE ZIP 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 basis of examination and/or Investigation, In my opinion d*IM oscurnal at
<br />Ms 110e, date and place and due to the meets) stated. (Signature and Title)-:
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO '❑ PROBABLY El UNKNOWN ❑ YES NO
<br />27. NAME. TITI AND ADDRESS OF CERTIFIER (Type or Print
<br />Carrie L. Valenta, MD, 7500 Mercy Rd, Omaha Nebraska, 68124
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. WAS CONSENT GRANTED?,.
<br />Not Applicable If 28a is NO ` ❑ YES [ I
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 8, 2020
<br />
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