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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF DOUGLAS COUNTY, NEBRASKA, IT CERTIFIES THE
<br />DOCUMENT BELOW TO BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE DOUGLAS COUNTY
<br />HEALTH DEPARTMENT, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />11/24/2020
<br />OMAHA, NEBRASKA
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<br />ADI POUR
<br />HEALTH DIRECTOR
<br />DOUGLAS COUNTY HEALTH
<br />DEPARTMENT
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Connie Joy Van Wie
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ord, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505.44-427$
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />82
<br />Sb FACILITY -NAME (If not
<br />12912 Burt Street.
<br />institution, give street and number)
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Si. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />ERIOutpatlent
<br />DOA
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November 10, 2020
<br />6. DATE OF BIRTH (Moi, Day, Yr.),.
<br />February 17, 1938
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />Other (SpecRYPDaughter's Home
<br />C] Hospice Facility
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 68154
<br />8d. COUNTY OF DEATH
<br />Douglas
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />#10 Kuester Lake
<br />Bb. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />De. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS'
<br />❑ YES ®NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Irwin Underberq
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name
<br />August Eugene Van Wie
<br />12. MOTHER'S -NAME (First,
<br />Leota Auble
<br />Middle, Maiden Surname)
<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 />Karly Olson
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
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<br />15. METHOD OF DISPOSITION
<br />▪ Budal 0 Donation
<br />❑ Cremation 0 Entombment
<br />[( Removal ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />16b. LICENSE NO.
<br />1495
<br />16e. DATE (Mo., Day, Yr.)
<br />November 14, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN
<br />Grand Island City Cemetery Grand Island
<br />17a. FUNERAL NOME 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 />111. PART I. Enter the chain of events- -diseases. Injuries, or complications -that directly awed the death. DO NOT enter terminal events such as cardiac arrest,
<br />letpketory *nein, of wntritular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines N necessary.
<br />IMMEDIATE CAUSE:
<br />a) Parkinson's Disease
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />in death)
<br />Sequentially list conditions, if
<br />any, Nadiag to the caua► listed`.
<br />on line a. _...
<br />Enter the UNDERLYING CAUSE
<br />ldisease or in4urylhat initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Cerebrovascular Disease
<br />STATE
<br />Nebraska
<br />17b, Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />Hypertension
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ No::
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<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />0 Pregnant at time of death
<br />❑ Not Pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown If pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident 0 Pending Investigation
<br />❑ Suicide ❑ Could not Ira determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />21d. WERE AUTOPSY FINDINGS AVAR,ABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d, INJURY AT WORK?
<br />OYES NO
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 10, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />November 12, 2020
<br />CITYITOWN
<br />23c. TIME OF DEATH
<br />09:43 AM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the camels) stated. (Signature and Title)
<br />James Ortman, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY ® UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<br />24b. TIME OF DEATH
<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 />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 7 NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a Is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />James Ortman, MD, 7823 Wakely Plaza, Omaha, Nebraska, 6811
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR 04o., Day, Yr.)
<br />November 19, 2020
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