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4ae:4:E. •Wit Uaa€t8x 3RWG,t„$,`�,)vte0;:liit lontrMgiato STATE OF NEBRASKA ,, ar hV:.Tz rattle, lDr! r> AaalattYrdtiRAa x'!ttttlt ittll $3sr aoi%r0i4MdtD.r? Astro WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELOW TO BEA 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 11/8/2021 LINCOLN, NEBRASKA Amended 202200220 SARAH BOHNENKAMP 04 4:-/LeelkAzr ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Mama Clara Wold CERTIFICATE OF DEATH 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 505-60-4227 5a. AGE - Last Birthday' (Yrs.) 69 8b. FACILITY -NAME (If not Institution, give street and number) 115 E Elm Street 8c. CITY OR TOWN OF DEATH (include Zip Code) Dannebroq 68831 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Howard 5b. UNDER 1 YEAR 2. SEX Female 5c. UNDER 1 DAY MOS. DAYS Bs. PLACE OF DEATH HOSPITAL ❑ Inpatient r FPJOuteat1.nt 0 DOA 9e. CITY OR TOWN Dannebroq HOURS MINS. 21 12471 3. DATE OF DEATH (Me., 1)67, September 20, 2021 8. DATE OF BIRTH (Mo., Day, Yr;) November 16, 1951 OTHER 0 Nursing Home/LTC ❑ Hospice Facility n wgek.o!'e Hams- - 0 Other (Specify) I8d. COUNTY OF DEATH Howard 9d. STREET AND NUMBER 115 E Elm: Street Bs. APT. NO. 9f. ZIP CODE 68831 9S INSIDE CITY LIMITS': !^xi YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married ❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Paul Wold 11. FATHER'S -NAME (First, Middle, Last, Suffix) Lue Allan 112. MOTHER'S -NAME (First, Middle, Maiden Surname) Clara Nielsen 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Paul Wold 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION Ea Burial © Donation ❑',Cremation 0Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER -SIGNATURE Gwen K. Hyronemus 16b. LICENSE NO. 1448 18c. DATE (Mo., Day, Yr.) September 25, 2021 16d. CEMETERY, CREMATORY OR OTHER LOCATION Cameron Cemetery CITY / TOWN Wood River STATE Nebraska ala. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska CAUSE OF DEATH (See instructions and examples) 17b. Zip. Code 88801 15. PART 1 Enter the chain of events- -diseases, Injuries, or complicatlons4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines x necessary. IMMEDIATE CAUSE: IMMEDIATECAUSE(Flbai :: al Alzheimers Disease Early Onset d!eaaea or conaxion resulting In death) Sequentially list conditions, If any,leading to the cause listed on fine a. Enter the UNDERLYING CAUSE (disown' or injury that Initiated the events resulting in death) LAST DUE TO, OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: c) APPROXIMATE INTERVAL onset to dead! 5 Years onset to death onset tD death DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 18. PART II. OTHER StGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting lin the underlying cause given in PART I. COVID related pneumonia 19. WAS MEDICAL. EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: ®_ Not pregnant within past year © Pregtnnt Is of death:. 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 pest year 22e. DATE OFINJURY (Mo!; Day, Yr.) 21a. MANNER OF DEATH ® Natural ❑ Homicide O Accident ❑ Pending Investigation 0 Suicide ❑ Could not be determined 22b. TIME OF INJURY 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger 0 Pedestrian 0 Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑YES Ea :NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 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 23a. DATE OF DEATH (Mo., Day, Yr.) September 20, 2021 23b. DATE SIGNED (Mo., Day, Yr.) Seoternber 21, 2021 23c. TIME OF DEATH 10:15 AM 23d. To the Who( my knowledge, death occurred at the time, date and place add due to the causes) stated. (Signature and Title) Steven Husen, MD STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 21P CODE 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PROi4GUNCED DED_ 24s. On the basis of examination and/or Investigation, In my opinion death OcWmed at the time, date and place and due to the cause(s) stated. (Signature and Tips) 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES ®NO 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES ] NO Q PROBABLY I] UNKNOWN 27. NAME, rt1TLE ND ADISRESS OF CERTIFIER (Type or Print Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES 0 NO, 28a. REGISTRAR'S SIGNATURE Amended 10/15/2021 Items 8d, 9b, Hall To Howard 11/8/2021 Item 15 Cremation To Burial 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) September 21, 2021 cn N , N.