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<br />STATE OFNEBRASKA )
<br />'ft,u1".f:li0(�Ulll
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA 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 OP ISSUANCE
<br />6!27/2022
<br />LINCOLN, NEBRASKA
<br />1. DECEDENTS -NAME (First, Middle,
<br />Elizabeth Elaine Obermil)er
<br />202205047
<br />.Lak,t e b4
<br />SARAH BOHNENI(AMP
<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 />Last, Suffix)
<br />4. CITY. AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kearney, Nebraska
<br />T. SOCIAL SECURITYNUMeER
<br />505-56-51 09
<br />ba. AGE - Last Birthday' -5b. UNDER 1 YEAR
<br />(Yrs.)
<br />7
<br />01
<br />E
<br />0
<br />to
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />4255 Michigan Avenue
<br />8c.'CITY OR TOWN OP DEATH•(Include ZIp Code)
<br />Grand Island 6$$83
<br />9a. RESIDENCE -STATE
<br />Nebraska:
<br />9d .STREET AND NUMBERt
<br />4255 Micll gain fivenue
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a, PLACE OFDEATH
<br />.:HOSPITAL ❑ Inpatient
<br />HOURS
<br />MINS.
<br />22 08649
<br />3. DATE 17F DEATH (Mo., Day Yr }
<br />June 16, 2022:.:
<br />G. DATE OF BIRTH (Mo., Day, Yt.)
<br />April 22, 1946
<br />OTHER 0 Nursing Home/LTC H
<br />❑`ER/Ou patient Ej Decedent's Home
<br />O DOA 0 Other (Specify)
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married 0 Never Married
<br />0 Married, but separated ]Widowed 0 Divorced 0 Unknown
<br />11. FATHERS RtAME (First, Middle, Last, Suffix)
<br />Leroy )Moffett
<br />13. EVER IN U.S ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />18. METHOD OF DISPOSI.TION
<br />® Burial O Donation
<br />❑;cremation 0Entoanbment
<br />❑'Removal ❑ Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />8d. COUNTY OF DEATH
<br />Hail
<br />9e. APT. NO.
<br />pica Facility
<br />9f. ZIP CODE
<br />68803
<br />9g INSIGNE CITY LimiTs!;
<br />YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />James Allen Obermiller
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Betty ` Elaine Riley
<br />14a. INFORMANT -NAME
<br />Jama Obermiller-Miller
<br />18a. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />A11 Faiths Funeral C tome, 2929 S. Locust Street, Grand island,.;Nebraska
<br />CAUSE OF DEATH (See in
<br />16b. LICENSE NO.
<br />1071
<br />CITY / TOWN
<br />Grand Island
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />16c. DATE (Mo...Dl
<br />June 21, 2025
<br />tructions 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 If. necessary.
<br />IMMEDIATE CAUSE:
<br />a) Coronary Artery Disease
<br />IMMEbIATE CAUSE 1PInai
<br />disease or condition insulting
<br />In death) ..
<br />Sequentlafly list conditions, if
<br />::any,,:ieading to the:eause tilted
<br />online a
<br />Enterttte UNDERL.YINO CAUSE
<br />(disease or injury that InitTatetl::
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Systolic Heart Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)Stage 3 Chronic Kidney Disease
<br />$TATE
<br />Nebraska
<br />11b zi I Cod
<br />68&:i
<br />APPROXIMATE INTERVAL
<br />et hi flea.)
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d) Ischemic Cardiomyopathy
<br />16. PARTIi, OTHER 5(0NIFICANT CONDITIONS -Conditions contributing to the death but nOttesti
<br />Transitionedto hospice due to progression of heart disease and renal disease •
<br />20. F::FEMALE
<br />❑ Not pragrlent N)titlt pdsl y44r
<br />❑ Pregnant et t#fae et death
<br />Not pregnant; but pregnant within 42 days of death
<br />❑. Not pregnant, but pregnant 49 days to t year before death
<br />tJnknovm Ifategnatxwtthin the past year
<br />224,DATE OF INJURY (Mo, Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />21a.MANNERQF.DEATH
<br />® .::
<br />Natural ❑ Nom(glde
<br />0 Accident ❑ Pending Investigation
<br />❑ Suicide 0 could not be determined
<br />22b. TIME OF INJURY
<br />the underlying cause given In PART I.
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />'._❑ Other (Specify)
<br />onset to death
<br />Years
<br />onset to deatt1
<br />Years
<br />• "onset to death
<br />...Years. .:
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONEROONTACTED?
<br />❑ YES I NO
<br />21c. 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,#arm, street, factory, office building, construction site, etc,(
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f LOcATION OF INJURY; STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 16. 2022
<br />23b DATE SIGNED (Mo., Day, Yr.)
<br />Jude 21, 2022
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />04:55 PM
<br />lad. To the best of my knowledge, death occurred at the time, date and place
<br />and due Intim .cause(s):stated. (Signature and Title)
<br />Michael A. Donner, MD
<br />28. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES ri NO. ID PROBABLY 0 UNKNOWN
<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 />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />..ZIP CODE •
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED::DEAD
<br />24e. f3a the bgais of examination and/or investigation, In my opinion death occurred at
<br />elle time, date and place and due to the cause(s) stated.. (Signature attdTifle)
<br />26a. HAS ORGAN.OR. TISSUE:DONATIONaEEN CONSIDERED?
<br />❑ YES illi NO
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YEs
<br />❑ N
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 23, 2022
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