|
1 1a Tli atk QlNANA
<br />rr t4 t' xa7W,NtiiklVNts , ttt ry -- agt6GA6MJry}�3"�•'�¢�
<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 />9/27/2021
<br />LINCOLN, NEBRASKA
<br />O
<br />d
<br />E
<br />2
<br />e3
<br />a,
<br />v
<br />0
<br />5
<br />202108G37
<br />,)(4. • r?_.i7 ,- =.tt4.1.k of apt
<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 />1. DECEDENTSNAME (First, Middle, Last, Suffix)
<br />Eunice Rae Stromberg
<br />4. CITY AND STATE (MI TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Manson, Iowa
<br />7. SOCIAL SECURITY NUMBER
<br />482-38-2093
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St, Francis
<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 />87
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL E Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />21 12333
<br />3. DATE OF DEATH (Mo.,; Day,
<br />September 10, 2021
<br />6. DATE OF BIRTH (Mo., Day. Yr.)
<br />October 1:$; 1933
<br />OTHER ❑ Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />0 Hospice Facility
<br />9d. STREET ANO NUMBER
<br />1407 W. John Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS"
<br />® YES Q NO
<br />10a. MARITAL, STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated 0 Widowed ® Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Helen Messenbrink
<br />Rov Berner
<br />13. EVER IN U.S ARMED FORCES? Give dates of service N Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Ellen Bartek
<br />14b. RELATIONSHIP TO DECEDENT
<br />Dauqhter
<br />15. METHOD OF DISPOSITION
<br />❑ Burlel 0 Donation
<br />®' cremat)ott' [] Entombment
<br />❑ Removal ` 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />September 15, 2021
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Crematory
<br />Grand Island
<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 />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events. .ii , Injures, or complications -that directly caused the death. DO NOT .mer 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 condaion resulting:'.
<br />in death)
<br />Sequentially Ilet conditions, If
<br />any, leading tothecause listed
<br />on line 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) Sepsis
<br />APPROXIMATE INTERVAL
<br />onset -to death
<br />Immediate
<br />onset to death
<br />Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Renal Failure
<br />onset tit death
<br />Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)Urinary Tract Infection
<br />onset to death
<br />Days,,;
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Comfort Cares and died in hospital
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />X20. IF FEMALE:
<br />© Not Magnant within peat year
<br />❑ Pregnant at time of Bergh
<br />0 Not ptegnam, but pregnant within 42 days of death
<br />0 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 0 Homicide
<br />0 Accident ❑ 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 />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES EI NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, 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 />22( LOCATION OF INJURY:! STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 10, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />September, 14, 2021
<br />23c. TIME OF DEATH
<br />07:05 PM
<br />23d. To Me best of inyknowledge, death occurred at the time, date and place
<br />and: due to the cause(s) stated. (Signature and Title)
<br />Michael A. Donner, MD
<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 death whirred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES J NO ❑ PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ❑ NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a is NO ❑ YES
<br />0 N
<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 />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 20, 2021
<br />-.4
<br />o
<br />r
<br />
|