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<br />STATE OF NEBRASKA
<br />PrI
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPYOF THE ORIGINAL RECORD ON RLE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH /S THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE ()F ISSUANCE
<br />3/8/2'022
<br />LINCOLN, NEBRASKA
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />al
<br />E
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (FIf8t, Middle, Last, Suffix)
<br />Barbara Jean Austin
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />SOCIAL SECURITY
<br />506-60-6977
<br />NUMBER
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health Bergen Mercy
<br />IC. CITY OR TOWN•OF DEATH (Include Zip Code)
<br />Omaha 68124
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />Bd,-STREETANDNUMBER s::.
<br />Pi:12555 KrugAve
<br />9b. COUNTY
<br />Douglas
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated 0 Widowed E Divorced 0 Unknown
<br />11, FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Robert J Lagsding<
<br />13. EVER IN U.S, ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />67
<br />Sb. UNDER'1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® inpatient
<br />❑ ER/Ou patient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Omaha
<br />HOURS
<br />MINS.
<br />21 16128
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November 13.2021
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />February 7, 1954
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Douglas
<br />9e. APT. NO.
<br />105
<br />9f. ZIP CODE
<br />68144
<br />❑ Hospice Faculty:'
<br />9g INSIDE"CITY LIMITS'
<br />YES ❑ NO
<br />10b NAME OF SPOUSE (First, <'Middle, Last, Suffix) 1f wife, give maiden name
<br />1 12. MOTHER'S -NAME (First, Middle, Maiden Sumame)
<br />Betty Mae Byersdorf
<br />14a. INFORMANT -NAME
<br />Shanda Kendall
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />0 Burial Donatktfl
<br />E Cremation t i Entombment
<br />0 Removal Other (Specify)
<br />16a. EMBALMER-SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION; CITY / TOWN
<br />Autumn Hills Cremation Services
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State);,
<br />Arbor Society, Inc., 2819 South 125 Avenue, Suite 367, Omaha, Nebraska
<br />Omaha
<br />CAUSE OF DEATH (See instructions and examples)
<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 H necessary.
<br />IMMEDIATE CAUSE (Final
<br />diseaee'or condltion result OS
<br />In death}
<br />Sequentially list conditions, If.
<br />any, leading to the cause listed.
<br />Whine a.
<br />Enter:tfie UNDERLYING CAUSE
<br />Idisease or Injury thatinitiated
<br />the events resulting in death).
<br />LAST
<br />IMMEDIATE CAUSE:
<br />a)Acute hypoxic respiratory failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE, TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />16c. DATE (Mo., Day, Yr.)'
<br />November 19, 2021
<br />STATE+
<br />Nebraska
<br />17b. Zip Code
<br />68144
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Days
<br />18. PART IL QTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death butnot resulting inthe underlying cause given In PART I.
<br />Diabefic keto ac(dosis, hypernetremia, septic shock with bacteremia unknown source.
<br />onset to death
<br />19. WAS MEDICAL > XAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ENO
<br />20, IF FEMALE:
<br />®Not pregnant wlttiin pastyeer
<br />❑•Pregnant at time of death
<br />❑ Not pregnant, bid pregltatnwithin 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 />22a DATE OFINJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />13 ❑YES ❑ NO
<br />22f. LOCATION OFINJU
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />0 Accident 0 Pending investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑'.. Paseenger
<br />0
<br />Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?.:.
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc(Specify)
<br />re
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />RY STREET & NUMBER, APT.NO. CITY/TOWN
<br />STATE
<br />7W CODE
<br />238. DATE OF DEATH (Mo., Day, Yr.)
<br />E November 13, 2021
<br />g 23d. To Rattiest of my kthjwledge, death occurred at the time, date and place
<br />2 anddue to the causes) stated. (Signature and Title)
<br />Sunil Nair, MD
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />November 20, 2021
<br />23c. TIME OF DEATH
<br />02:16 PM
<br />1
<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 tete bertha Of examination and/or investigation, in my opinion death 04curted at
<br />the.tlme, date and place and due to the cause(s) stated. (Signature and Thiel.
<br />25, DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ❑:NO ❑PROBABLY E UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES Idl N0
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO 0 YES ❑,
<br />'): NAME, T(TLEAND ADDRESS OF CERTIFIER (Type or Print
<br />Sunil Nair, MD, 7500 Mercy Dr, Omaha, Nebraska, 68124
<br />28a. REGISTRAR'S SIGNATURE ,.
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 23, 2021
<br />Co
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