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<br />K STATE OF NEBRASKA
<br />VANS
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<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 />ts?ATE OF ISSUANCE
<br />....................... ....... .......
<br />11116/2022
<br />;
<br />so CITY oR TOWN
<br />Liioif'r 6861
<br />202300304
<br />SARAH BOHNENKAMP j
<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 />DEIfEDENTS;)tAME (HI'Mf. Middle, Last;. Suffix)
<br />Iene Val Oldei bak
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Independence, Missouri
<br />T so SAL SECURITY NUMBER
<br />S71'68~1104
<br />8b: FACILITY -NAME (If net institution, give street and number)
<br />48011': South; 58th Street
<br />OF DEATH (Include Zip Code)
<br />6
<br />E -STATE:
<br />ska
<br />90 ST`REE(ANDNUMBER.
<br />121 Monument Rd
<br />9b. COUNTY
<br />Hall
<br />8a..AGE Last Birthday>
<br />(Yrs )
<br />76
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OP DEATH
<br />HOSPITAL ❑ Inpatient
<br />] ER/Ou patient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />3. DATE Of
<br />Novembt
<br />2215757
<br />lMo1,a>r�r)
<br />1022
<br />6. DATE OF BIRTH (Mo., Day, Yr
<br />January 8, X548
<br />OTHER 0 Nursing Homt
<br />0 Decedent's Home
<br />® Other (Specify)Other
<br />ad. COUNTY OF DEATH
<br />Lancaster
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />Married, but separated . ❑ Widowed l) Divorced 0 Unknown
<br />t I FATHERS NAME (First; `:: ` Middle,
<br />Cftf ton Erliest, Jac by
<br />rat,''.
<br />Suffix)
<br />'13. EVER .NU S ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit) No
<br />1" METHOD OF DISPOSITION
<br />© Burfet O D4riation .
<br />Ct'snlatlon'; 1 Entomtm!
<br />Oval Outer (Specify)
<br />9c. CITY OR TOWN
<br />Doniphan
<br />9@. APT. NO.
<br />9f. ZIP CODE
<br />68832
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give malden,mene
<br />14a. INFORMANT -NAME ">
<br />Sandy Vance
<br />111a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />lad. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Lincoln Cremation Service
<br />17s. FUNERAL HOME NAME; AND MAILING ADDRESS (Street, City or Town, State)...
<br />12ol er &Stine #n(; 300;0 Street, Lincoln, Nebraska •
<br />1$. PART.
<br />2 MOTHER'S -NAME (First, Middle,
<br />Hazel ;:Eleanor Gordon
<br />16b. LICENSE NO.
<br />CITY/ TOWN
<br />Lincoln
<br />CAUSE OF DEATH (See 1nstructIt ns°and examples)
<br />14b. RELAT iSHIP O DECSDENI
<br />Daughter
<br />16c. DATE (Mo., I y, tYr )
<br />Novef»be
<br />iter the chain of Waft.. -diseases, injuries, or complicationsdhat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />arrest, 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 />IMMEIftATH C11f181t;Pirlet
<br />dleed8s or Wildhialtrastilete
<br />In death)
<br />a) CHRONIC OBSTRUCTIVE PULMONARY DISEASE
<br />JE TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Ercet311a t ERLYJGIS CAUSE
<br />sease ckinjury death) tfian t
<br />the(dievents resulting in death)
<br />LAST ....
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />onset tikededlly
<br />UNKKN
<br />onset too
<br />ones
<br />on
<br />18. PART ft OTHER SiGNWICANT CONDITIONS -Conditions contributing to the
<br />20.:.IF FEMALE:
<br />Not pre(ptaln w1.tion;p
<br />x /..pre at tdnn M death
<br />_ Nat irregnam, butpragltatttwithin 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />© Unlrnowq. N prepnaM v ithin the put year
<br />ATE OF INJURY (Mo.;:Day, Yr.)
<br />Bath but not resulting inthe
<br />21a. MANNER OF DEATH,,,
<br />® Natural 0 H4ntickle'
<br />0 Accident 0 Peitallm Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />DESCRIBE
<br />22c. PLAC
<br />denying cause given in PART I.
<br />23b IF TRANSPORTATION INJURY
<br />OriverlOperator
<br />❑ Passenger.
<br />0 Pedestrian'
<br />0 Other (Specify)
<br />19. WAS MEDIGAIAXAMINEN.
<br />OR CORONERr�. TACTED'7
<br />® YES CI NO
<br />21c. WAS AN AUTOPBY.PERf'.+t9RMED?
<br />0 YES 1 N .
<br />21d. WERE AUTOPSY=FINDINGS AVAH.A81
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ Nig.,
<br />OP1NJURY-Athate; ferns, street, factory, office building, construction site, etC• tf
<br />HOW INJURY OCCURRED
<br />LOCATION OF INJURY -:STREET & NUMBER, APT.NO.
<br />a. DATE OF DEATH (Mo., Day, Yr.)
<br />November"! 2, 2022
<br />. DATE SIGNEOlito., Day, Yr.) TIME OF DEATH
<br />November 14; 2022 12:40 PM
<br />refteeotitOrkiipwledge, death occurred at the time, date and place
<br />Andlifietetim'aiiiise(s) stated. (Signature and Title)
<br />•
<br />Nathan B. Green, MD
<br />25..)31OITOOACCOUSE,,CipNTRIINJTE TO THE DEATH?
<br />. NAME. 7iTLEAND ActongstoF CERTIFIER (Type or Print
<br />Natharfa. Greett,MD, 5715 S 34th St Ste 100, Lincoln, Nebratka, 68616
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) TIME PROMOUIVOIOD&AD
<br />24e. On tbe IMMS of examination and/or investigation, In my opinion death tenoned at,
<br />§ the Um@ date and place and due to the causels) stetted. (Signature andlrit) • ,
<br />28a. HAS ORGAN OIR TISSUE DONATION PEEN CONSIDERED?
<br />28a. REGISTRAR'S SIGNATUREC"--
<br />28b. WAS CONSENT GRANTED
<br />Not Applicable If 28a Is NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 16, 2022
<br />
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