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<br />WHEN THIS COEYCA�'7RIES THE RAISED SEAL OF STATE OF NEBRASXA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA
<br />Tout COPT OF THE ORIGINAL RECORD ON FILE' WITH THE NEBRASM :DEPARTMENT OF HEALTH AND
<br />KUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />12/812022
<br />LINCOLN, NEBRASKA
<br />E
<br />E..
<br />I
<br />O
<br />0
<br />a-
<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 />1. RECEDE 4T1$ -NAME :(FIrst, Middle, Last, Suffix)
<br />Jean Ann :Jakob
<br />CERTIFICATE OF DEATH
<br />4. orry AND STATE OR TERRITORY, OR FOREIGN, COUNTRY OF BIRTH
<br />Holdrege, Nebraska
<br />7 $QclA.S CURITYNUMBER
<br />608 48 1;080
<br />8b.'FACILITY-NAME (If not Institution, give street and number)
<br />Nebraska Heart Hospital
<br />Sc. CITY OR TOWN OF t'1EAATH (Include Zip Code)
<br />:)neoln 88526
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />9d, STREET 1ND sustaare
<br />2508 i!ti�efs(de Drive
<br />9b. COUNTY
<br />Hall
<br />Se. AGE - Lain Birthday
<br />(Yrs.)
<br />71,
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />PLACEOP DEATH
<br />HOSPITAL Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />10a MARiTALSTATI3s AT TIME OF DEATH El Married ❑ Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />11FATHERS49AME.(Flrst, Middle, Last, Suffix)
<br />red J hnston
<br />I3 EVER IN () 8 ARMED FORCES? Dive dates of service If Yes.
<br />(Yes, No, orUnk.)No
<br />1$. METH00 OF DISPOSITION
<br />j)(j t3tltfai j Dof►atlon
<br />Cremation ❑Entombment
<br />RsmovJ ,❑ other (Speclfll)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH, (Mo:, Day; yt)
<br />January '62.0.11:0!i!,..
<br />6. DATE OF'BIRTH (Mo., Day, Yr)
<br />December 27.;.19
<br />6a.
<br />OTHER ❑,Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Lancaster
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />INSIDE OITY.tIMTTO
<br />YES ?Na
<br />1Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give
<br />David Alan Jakob
<br />14a. IN FORMANT,NAME
<br />David Alan Jakob
<br />16a. EMBALMER -SIGNATURE
<br />William M. Cicmanec
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a FUNERA(HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />1AU Faith$ Funeral' Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />12. MOTHER'S•NAME (First, Middle, Maiden Surname
<br />Nona Gentry
<br />16b. LICENSE NO.
<br />1036
<br />CITY / TOWN
<br />Grand Island
<br />14b, RELATIONSHIP 7.0"
<br />Husband
<br />18r.. DATE (Mo., Day, Y.
<br />January 1, 2191=
<br />NT'
<br />TATE
<br />Nebraska
<br />CAUSE OF DEATH (See instructions and examoles)
<br />18. PART I. Emerf s thaln of events- .dtessitsa, in/wta, or complleaaons4hat directly caused the death. DO NOT WSW Mfldall rapt, IMO - _..
<br />respiratory onset,: or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />es of scArsesaw a) Acute Myocardial Infarction
<br />tl $pee 0rfofditt6n resulting
<br />in rdeathf
<br />Sequentially list conditions, If
<br />any, leading to the cause listed
<br />online a,
<br />f filter the UNRERtVING use
<br />(d[ssaae or in)urythdt InhNted
<br />ihevents resulting to death)
<br />LAST
<br />DUET
<br />b)
<br />OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR A CONSEQUENCE OF:
<br />d)
<br />1* PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in thnunderlying cause given In PART I.
<br />r20. IF FEMALE::
<br />Not pregnant within:
<br />a Pregnant attlmeCtdeath
<br />❑' Not pregnatitt, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 slays to tel year before death '.
<br />©: unknown ft pregnant Within the past year
<br />•2Za. DATE AF j*UURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES .:: {D NO
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homudide
<br />❑ Accident 0 Pending investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />©Oliver/operator
<br />.: ❑ Passenger
<br />❑ Pedestrian
<br />❑. Other (Specify),
<br />19. WAS MEI11CAl EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES 5j NO
<br />21c. WAS AN AUTOPSY PERFORMED.?
<br />❑ YES iA(NO
<br />21d. WERE AUTOPSYFriNDINGS AV
<br />TO COMPLETE (*USE OP DEA'
<br />0 YES El, NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site ets::I
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f.LOCAT1ONOF1NJUIY1 STREET & NUMBER, APT.NO.
<br />u
<br />O 911. Tome hast of my knowledge, death occurred at the time, date and place
<br />hod due tb tits causes) stated. (Signature and Title)
<br />Anal Jain, MD
<br />23a DATE OF DEATH (Mo., Day, Yr.)
<br />January 6, 2011
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />ilelUa[v 1Q. 2011
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />10:46 PM
<br />28. DID TOBACCO USE: CONTRIBUTE TO THE DEATH?
<br />YES ❑ NO PROBABLY ® UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo,, Day, Yr.)
<br />24c.. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />I'PICDDE.:..
<br />24b. TIME OF
<br />24d. TIME PRONOUNCED DEAD-::,
<br />14e 1fl tna basis of examination and/or investigation, In my cordon Aaath adcurred(nt
<br />'the that, date and place and due to the stigmata) staled. (Signatre end'itas).
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />® YES 0 NO
<br />21. NAME, TITLE AND A6 ESS OF CERTIFIER (Type or Print
<br />Anuj Jain, MD, 1440 S 91st St, Lincoln, Nebraska, 68526
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?.:::::
<br />Not Applicable If 28a is NO . I YES.
<br />28b. DATE FILED BY REGIST
<br />January 12, 2011
<br />R (Mo., Day, Yr.)
<br />
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