|
�,,;�a)rfGrW�e.n::�t(111�III,Et�i�l.� rGul�O�tia,
<br />u4 Ir."y;ll!d'hil.i�,1i111VA1�ilr�r�r'Di)�rrrN4r t� r r �t�gl
<br />y ,:__,. /ll/(111i, D � .16/1111111u_;:•.
<br />1011/,1tl�lliiy unan:l
<br />%34471rllhti��°;
<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 OFISSUANCE
<br />........................................
<br />1/11/2021,:
<br />LINCOLN, NEBRASKA'
<br />202208499
<br />v
<br />8
<br />1
<br />1
<br />t1 44,447.
<br />SARAH
<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 />1 DEGEDENr.E NAME.(F'rst, Middle, Last, Suffix)
<br />Barbara ;;lean Ogden
<br />4. C#TY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand island, Nebraska
<br />7 SOCIAL SEEURlTY NUMBER
<br />505-42-$288
<br />8b. FACILITY -NAME (Wnot Institution, give street and number)
<br />Tiffany Square Care Center
<br />8a CITY OR TOWN OP DIATH (Include Zip Code)
<br />Grand isl8nd. 68863
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />9d, S'T`REET ANO NUMBER
<br />12748 Halling Road
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />511 UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL ©!Inpatient
<br />❑ ER/Outpatient
<br />0 DOA
<br />DAYS
<br />9b. COUNTY
<br />Hall
<br />10a MARITAL STATUS AT TIME OF DEATH ..g1 Married 0 Never Married
<br />Married, but separated 0 Widowed ❑ Divorced 0 Unknown
<br />11 FATHER S-NAAME (Rrst, Middle, Last, Suffix)
<br />FsiitittEe WeQner
<br />13.EVER.IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />es, No, or Unk.) No. -
<br />15. METHOD` OF DISPOSITION
<br />Burial ❑Donation
<br />Crentattoni ❑ Erten bment
<br />Removal < ❑other(Specify)
<br />9c. CITY OR TOWN
<br />Wood River
<br />10b. NAME OF SPOUSE (First,
<br />Richard Ogden
<br />HOURS
<br />MINS.
<br />00057
<br />S: DATE OF DgATil.(ii4iSql*iS1S9
<br />January 2 2d11
<br />6. DATE OF BIRXii._(Mo., Day, r )
<br />September 6 1
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />ae Fagility
<br />9g INSIDE CItY:L#Mf's>
<br />(. YES C NO
<br />12. MOTHER'S -NAME (First, Middle, Malden
<br />If Elizabeth Lueth
<br />14a. INFORMANT.NAME
<br />Richard Ogden
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCov
<br />16b. LICENSE NO.
<br />. 1191
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a, FUNERALHOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand island, Nebraska
<br />CITY /TOWN
<br />Grand Island
<br />14b. RELATIONSHIP TODECEDENT
<br />fYiluSe
<br />6c. DATE (Mo., Day,.Yr
<br />January 11 2021
<br />:STATE
<br />Nebraska
<br />17)1..4.
<br />C
<br />68.801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART L 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 8' necessary.
<br />IMMEDIATE CAUSE:
<br />a1COVID=19.Pneumonia
<br />IMM.EDiATE CAUSE (retiet
<br />• d,eeasefir gondht nt5*uitin9,3
<br />kt daadtt .
<br />Sequentially list conditions,if
<br />any,: leading to the cause gsted
<br />Enter: the INDIM YINO A ...
<br />(dlse558 or injufy that tnittated.
<br />the events: resulting in death)
<br />LAST',
<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 />1& PARTII OTTER SiGNkwtCANT CONDITIONS -Conditions contributing to the Beath tut not resulting in the underlying cause given in PART!.
<br />Parldnsnn 6, :Normal Pressure Hydrocephalus With Stent, Chronic Blood toss Anemia
<br />20. IFFEMALE:.
<br />Not pregnen? wabht past year
<br />❑'Pregnant at titre e} death::.
<br />0,1dRt progriatd, but pregnant within 42 days or dead
<br />pregnant, but prslingnt 49 days to 1 year befo
<br />nknown If pregnant w1thin the past year •
<br />22a,:DATE DF IiI1JURY (Mos;: Day, Yr.)
<br />22d. INJURY AT WORK?
<br />:❑ YES ❑ No
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />o Accident 0 Pending Investigation
<br />0 Suic de 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22f LOCATION; OFtN,IURt STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 2, 2021
<br />21b. IF TRANSPORTATION INJURY
<br />Driver/operator
<br />O. Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />19. WAS MEDIOAI«:
<br />t?!t CORONER CO)
<br />❑ YES Ni
<br />#MINEf
<br />'ACTED?
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />21d. WERE AUTOPSY FINDINGS AVAtI ABB E
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES'. ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction alto, etc.( s
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Jat1u(s1l1<1"t' 2Q21
<br />�d iq:ltie befit o1 i1ny knowledge, death occurred at gra time, date and place
<br />artd due to the seuse(s) stated. (Signature and Title)
<br />Richard Fruehling, MD
<br />23c. TIME OF DEATH
<br />09:40 PM
<br />25 DILL TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES NO S'::I PROBABLY 1]., UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />240. TIME OF DEATH"
<br />24d TIME PRONOUNCED DEAD
<br />24e. 00 the basis of examination and/or investigation, in my epkllon death accurrad al
<br />• the 0me; date and place and due to the cause(s) stated. (Signature ad Tide) •
<br />•
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES RI NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable et 26a Is NO 0 YES;
<br />27., NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Rickard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRARS SIGNATURE
<br />6k-44-16 80-1L/Leiriket-tni-
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 7, 2021
<br />o
<br />(0
<br />01
<br />
|