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f WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 7/27/2020 LINCOLN, NEBRASKA 202104854 SARAH BOHNENKAMP f ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES DEATH 20 09119 Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death. I 1. DECEDENTS.NAME (First, Middle, Last, Suffix) Linda Ellen Mars 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) June 25, 2020 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Grand Island, Nebraska (Yrs.) 74 MOS. DAYS HOURS MINS. October 22, 1945 7. SOCIAL SECURITY NUMBER 505-56-5474 8a. PLACE OF DEATH HOSPITAL © Inpatient OTHER ❑ Nursing Home/LTC ❑'Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 0 ER/Outpatient 0 Decedent's Home 0 DOA 0 Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1615 W Louise 9e. APT. NO. 91. ZIP CODE 68801 9g. INSIDE CITY LIMITS 2 YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married ❑ Married, but separated ❑ Widowed ® Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name 11. FATHER'S -NAME (First, Middle, Last, Suffix) Paul Hermsmeyer 12. MOTHER'S -NAME (First, Middle, Malden Surname) Lillie Sautter 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Link.) No 14a. INFORMANT -NAME Daniel Mars 14b. RELATIONSHIP TO DECEDENT Son 15. METHOD OF DISPOSITION ❑ Burial ®Donation 16a. EMBALMER -SIGNATURE Benjamin Hall 16b. LICENSE NO. 1305 16c. DATE (Mo., Day, Yr.) June 26, 2020 ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Nebraska Anatomical Board Omaha Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events ouch as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Multifocal Pneumonia disease or condition retuning onset to death in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) Failure To Thrive any, leading to the cause listed lirle onset to death on e. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury that initiated onset to death the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I. Acute Renal Failure, Acute Respiratory Failure 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE: gi Not pregnant within past year ❑ Pregnant at time of death 21a. MANNER OF DEATH ® Natural ❑ Homicide 0 Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? - ❑ YES; NO 0 Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year ❑Suicide ❑Could not be determined 0 Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY -STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) June 25, 2020 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) June 27, 2020 23c. TIME OF DEATH 11:13 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Manoj Survanaravanan, MD 24e. On the basis of examination and/or investigation, In my opinion death occurred at the time, date and place and due to the cau e(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES 0 NO 0 PROBABLY ® UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 2 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Manoj Suryanarayanan, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE ) 6t4.Q /L,-f?.et-rvt_ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) July 15, 2020 'ro/