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<br />STATE OF NEBRASKA r
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<br />WHEN THIS r' 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 />8/18/2020
<br />LINCOLN, NEBRASKA
<br />202103611
<br />p@ dd )y Qa_ j
<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 />2010543
<br />0
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<br />e ▪ 11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />I Fred Peivit
<br />1. DECEDENT'S=NAME (First, Middle, Last, Suffix)
<br />Jacqueline Rose Foster
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr,)
<br />August 10, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Lidgerwoad, North Dakota
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />70
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day,"
<br />January 5,.195Q.
<br />7. SOCIAL SECURITY NUMBER
<br />502-50-6434
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />817 Redwood Road
<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 />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />led. COUNTY OF DEATH
<br />Hall
<br />0 Hospice Facility
<br />9d. STREET AND NUMBER
<br />$17 Redwood Road
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />99 iNStDE,ClTY LIMITS
<br />To, YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />William Thomas Foster
<br />O
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Clara Haase
<br />13.`EVER IN U,S, ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit.) No
<br />14a. INFORMANT -NAME
<br />William Thomas Foster
<br />14b. RELATIONSHIP TO DECEDENTi'
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑`Burial 0 Donation
<br />®L
<br />Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />18c. DATE (Mo., Day, Yr.)
<br />August 11, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY / TOWN
<br />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 />1.70. Zip;Cods
<br />68801
<br />18. 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 11 necessary.
<br />IMMEDIATE CAUSE:
<br />a) Pancreatic Cancer Metastatic
<br />IMMEDIATE CAUSE (Final
<br />disease or condition making_:.
<br />in death)
<br />Sequentially list conditions, if
<br />any, Netting to the: cause listed
<br />on One a.
<br />Enter:the UNDERLYING CAUSE
<br />(disease or injury that Initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />APPROXIMATE INTERVAL
<br />onsetto death:
<br />3 Years
<br />onset to death
<br />onset todeath
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART IL. OTHER SIGNIFICANT CONDITIONS-Condit)ons contributing to the death but not resulting in the underlying cause given in PART I.
<br />20.� El
<br />FEMALE:
<br />IAl Not pregnant withlipett year
<br />0 pregnent at tithe at death
<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 />0 Unknown if pregnent within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />D YES❑ NO
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other(Specify)
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />O YES ®: NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<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 />22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 10, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Auf1U&t 11, 2020
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />12:14 AM
<br />ad. To Ma beet of my knowledge, death occurred at the time, date and place
<br />and due ID the cause(s) stated. (Signature and Title)
<br />Ryan Ramaekers, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES El NO ha PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />7JP.CODE
<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 deaths
<br />thetiime, date and place and due to the eau MO stated. (Signature erne
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />orretl: et
<br />le)
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO ❑ YES
<br />0
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan Ramaekers, MD, 2116 W. Faidley Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRARS SIGNATURE
<br />Dt-4aJi �a it x n �a ,zz�
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 12, 2020
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