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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 OF ISSUANCE
<br />4/30/2020
<br />LINCOLN, NEBRASKA
<br />20210934i
<br />-�44, ,) ItLaket.f,rf
<br />SARAH BOHNENKAMP f
<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. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Susan Diane Igo
<br />4. CITY AND STATE ORTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Danville, Illinois
<br />5a. AGE - Last afrthday
<br />(Yrs.)
<br />64
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS. DAYS
<br />HOURS MINS.
<br />20 05282
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 23, 2020
<br />8. DATE OF BIRTH (Mo., Day, Yr:)
<br />October 27, 1955
<br />r� T. SOCIAL SECURITY NUMBER
<br />al 334-52-0297
<br />c 8b. FACILITY -NAME (If not Institution, give street and number)
<br />I 2407 Cottonwood Road
<br />2 se. CITY OR TOWN OF DEATH (Include Zip Cods)
<br />A Grand island 68801
<br />ca 9a. RESIDENCE -STATE
<br />I Nebraska
<br />e 9d. STREET AND NUMBER
<br />2 2407 Cottonwood Road
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />r 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />9b. COUNTY
<br />Hall
<br />It FATHER'S -NAME (First, Middle, Last, Suffix)
<br />- Gayle Leslie Shuck
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yea.
<br />O (Yes, No, or Unk.) No
<br />u 15. METHOD OF DISPOSITION
<br />g 0 Burial 0 Donation
<br />S ❑ Cremation 0 Entombment
<br />cE Removal ❑ Other (Specify)
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑' Inpatient
<br />ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />OTHER 0 Nursing Home/LTC
<br />E Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />© Hospice Faciifhf
<br />9g< INSIDE CITY LIMITS
<br />®Yes ❑ No '>
<br />1Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Patrick O'Hern Igo
<br />112. MOTHER'S«NAME (First, Middle, Malden Surname)
<br />Rita Ann Tomlinson
<br />14e. INFORMANT -NAME
<br />Patrick O'Hern Igo
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />16b. LICENSE NO.
<br />1397
<br />16c. DATE (Mo., Day, Yr.)
<br />April 27, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Springhill Cemetery
<br />CITY / TOWN
<br />Danville
<br />STATE
<br />Illinois
<br />17e. 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 />17b. Zip Code
<br />68801
<br />18. PART I. Enter the chain of events- -diseases, injuries, or complications -hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />3 ' respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on • IIM. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Heart Failure
<br />IMMEDIATE CAUSE (Final
<br />E disease or condition, resulting
<br />13
<br />ai
<br />a
<br />d
<br />dl
<br />O
<br />In death}
<br />Sequentially list conditions, H
<br />any, leading to the cause listed
<br />On HIM B.
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury that Initiated
<br />Vat the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Diabetes
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Heart Disease
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Minutes
<br />onset to death
<br />Years
<br />onset to>dsath-
<br />Years'
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART I. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />History Of Heart Issues
<br />ret
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />E YES ❑ NO
<br />0. IF FEMALE:
<br />® Not pregnant within Pest year
<br />©Pregnant at time of death
<br />but pregnant within 42 days of death
<br />0 Not pregnant,
<br />• ❑ Not pregnant, but pregnant 43 days to 1 year beton death
<br />O ❑ Unknown If pregnant within the peat year
<br />C
<br />I-
<br />S 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />35 • ❑ YES ❑ NO
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />❑. Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />❑ 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, att. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET& NUMBER, APT.NO.
<br />LW
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />o
<br />Ft
<br />to �
<br />�'
<br />g ~ f
<br />d
<br />CITY/TOWN
<br />STATE ZIP COPE
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23e. TIME OF DEATH
<br />tad. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Tis)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO PROBABLY 0 UNKNOWN
<br />z
<br />ls• :
<br />E
<br />• 01
<br />6
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />April 24, 2020
<br />24b. TIME OF DEATH
<br />Approx. 04:40 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />April 23, 2020
<br />24d. TIME PRONOUNCED DEAD
<br />05:34 AM
<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 causes) stated. (Signature and Yids)
<br />Christopher J Harroun, Hall County Attorney
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO ❑ YES 0 NO
<br />26e. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES
<br />ENO
<br />127. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />11
<br />Christopher J Harroun, Hall County Attorney, 231 S Locust St, Grand Island, Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATURE
<br />6k--14-1/1Ba k Lf
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 27, 2020
<br />
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