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4.
<br />est
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />1/31/2022
<br />LINCOLN, NEBRASKA
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<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 />22 00940
<br />1. DE EDENT'S-NAME (First, Middle, Last, Suffix)
<br />Linda Kay Matthes
<br />2. SEX
<br />Female
<br />4. CITY AND STATE QR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Palmer, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />69
<br />'5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 16, 2022'
<br />6. DATE OF BIRTH(Mo., Day, Yr.)
<br />4r.
<br />ds
<br />C
<br />g 22d. INJURY AT WORK? 122e. DESCRIBE HOW INJURY OCCURRED
<br />ao ❑YES (JNO
<br />7. SOCIAL SECURITY NUMBER
<br />505-72-2795
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />•
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER,
<br />608 Hillside Dr
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH El Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Harvey Zichek
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />® ER/Ou patient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Cairo
<br />September 17, 1952
<br />OTHER 0 Nursing Homs/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68824
<br />❑ Hospice Facfiffty
<br />9g, IN(tDE C17Y UNITS
<br />® NES Q NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />John Matthes
<br />1 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Deloris May
<br />14a. INFORMANT -NAME
<br />John Matthes
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD QF DISPOSITION
<br />❑'Burial [� Donation
<br />f ] Cremation. ❑ Entombment
<br />[] Removal ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Oily, Yr.)
<br />January 20, 2022
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY / TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Ail 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 -that directly caused the death. DO NOT enter 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) acute hypoxic respiratory failure
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In death);:: _.
<br />Sequentially list conditions, if
<br />any, leading to the cause gated
<br />on tine a
<br />Ernst !hit 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)heart failure and emphysema
<br />APPROXIMATE INTERVAL
<br />onset todeath
<br />Days
<br />onset to death
<br />Months
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />onset tditeath
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18, PARTIL OTHER SIGNI(ICANT CONDITIONS -Conditions contributing to the death bu
<br />not resulting in the -underlying cause given in PART I.
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within pest year
<br />0 Pregnant at ams of death
<br />0 Not pregnant, 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 0 Ponding Investigation
<br />0 Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />NO
<br />0 YES
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES ❑ NO
<br />22a. DATEOF INJURY (Mo Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, att. (Specify)`
<br />21. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 16, 2022
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 20. 2022
<br />23c. TIME OF DEATH
<br />07:15 PM
<br />23d, To the best of my knowledge, death occurred at the time, date and place
<br />end due 10 the aause(s) stated. (Signature and Title)
<br />The Wut Yee, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES 0 NO 0 PROBABLY ® UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP CODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the Oasis o1 examination end/or investigation, In my opinion death occurred et
<br />the time, date and place and due to the cause(s) stated. (Signature anti 'rifle)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO 0 YES 0 NO;
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />The Wut Yee, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />CO
<br />January 26, 2022
<br />OD
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