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<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 OF ISSUANCE
<br />6/8/2020 ,'c?.P)
<br />SARAH BOHNENKAMP f
<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 />LINCOLN, NEBRASKA
<br />Si
<br />a,
<br />E
<br />1 pecepENTS.NAME (First,
<br />Edythe W;Johnson
<br />4. WY AND
<br />Middle, Last, Suffix)
<br />TE OR TEf2RITORY, OR
<br />Litchfield, Nebraska
<br />FOREIGN COUNTRY OF BIRTH
<br />?:SOCIA( SECURaTY NUMSER
<br />507-36.2716;
<br />5a. AGE Last Birthday
<br />(Yrs.)
<br />87
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />CMI Health St. Francis
<br />8t. CITY OR TOWN OF DEATH (InctudeZip Code)
<br />Grand island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER,.
<br />310 W tith;Street
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />6c. UNDER 1 DAY
<br />MOS. DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />® ER/Ou patient
<br />0 DOA
<br />9b. COUNTY
<br />Hall
<br />10a. MARrTAL STATUS AT'11ME OF DEATH ® Married ❑ Never Married
<br />❑ Marded, but separated ❑Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME AFIrst, Middle, Last, Suffix)
<br />Joseph A Cornford;
<br />13. EVER IN U.S. ARMED EORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />16. METHOD OF DISPOSITION
<br />❑ Burial ❑ Donation'
<br />® Cremation ❑ Entombment
<br />❑ Removal ❑ Othea specify)
<br />9c. CITY OR TOWN
<br />Wood River
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Ma , Day Yr.)
<br />May 27, 2020:!:„ii::.
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />1-lall
<br />9f. ZIP CODE
<br />68883;,
<br />10b.;NAMEOFSPOUSE (First, Middle, Last, Suffix) If
<br />Dale F Johnson
<br />14a. INFORMANT -NAME
<br />Dale F Johnson
<br />168. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12. MOTHER'S -NAME (First, Middle,
<br />Ruby P Maiwald
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION .'
<br />Westlawn Memorial Park Crematory
<br />16b. LICENSE NO.
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Livingston -Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />+(espice Facility
<br />Ifs, give maiden r(
<br />9 ft4SIDE C(Ty LIMITS.:
<br />® YEs .i ❑ j4,0
<br />CITY /TOWN
<br />Grand Island
<br />CAUSE OF DEATH(See instructions and examples)
<br />18. PART CEnter the Chain of events- -diseases, injuries, or compiications•thatdirectly 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 />omor TEeAuse(Final a) Major Head Injury, Right -side Subdural Hematoma and
<br />disease or sonditiOn resulting
<br />in death('
<br />Sequentially list conditions, if - b)
<br />any, leading to the cause listed
<br />Subdural Hematoma - Pneumocephalus
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLt'If1G GAVS6 ' C)
<br />(disease or'injury that Initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />Subarachnoid Hemorrhage, Left
<br />14b. RELATIONI
<br />Spouse
<br />I?. TO DECEDENT':;:
<br />18c. DATE (Mo., Day, Yr.)
<br />June 2, 2020
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68803
<br />APPROXIMATE INTERVAL
<br />onset tadeath::,,
<br />Minutes.
<br />18. PART 8 OTHER SH3NIFICANTCQNDITIONS-Conditions contributing to the death bttt not resulting in:ahe underlying cause given In PART I.
<br />Acute. Respiiatf5ry Failure,( Many Fractures Including Skull, Scapula, Rites Legs And Arms;
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONERCONTACTED..
<br />1 YES
<br />20. IF FEMALE:
<br />❑ id. pimgnarivrldtin peel year
<br />❑ Pregnant attfine of death
<br />0 Not pregnald,•but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown If pregnant within tIle past yaar
<br />'2a. DATE OF INJURY (MO, Day, Yr:)
<br />May..:27.2020'
<br />22d. INJURY AT WORK?
<br />13 YES' ® NO
<br />21a. MANNER OF DEATH
<br />0 Natural ❑ Homicide_
<br />® Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />Unknown
<br />21b. IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21r, WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY EINOINGSAVAII,ABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES' ❑„NO,.
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site etc< (
<br />Unknown .
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />Per medical records, Decedent struck her head and fell about 10-12 steps.
<br />2f. LOCATION OF INJURY-STREET.&.NUMBER, APT.NO. ' CITY/TOWN
<br />Unkr1Owf1.....
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />23d. To lbeItestbf my knowledge, death occurred at the time, date and place
<br />and due tothe caiise(s) stated. (Signature and Title)
<br />25. DID .TOBACCO '-'.USE CONTRIBUTE TO THE DEATH?
<br />❑:YES E: NO El::PROBABLY 0 UNKNOWN
<br />27. NAME. TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Sarah Carstensen, Hall County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />STATE
<br />Nebraska
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />June 2, 2020
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />May 27, 2020
<br />ZIP
<br />24b. TIME OF DEATH
<br />07:16 PM
<br />CODE
<br />24d. TIME PRONOUNCED DEAD
<br />07:16 PM
<br />84p. Oft the basis of examination and/or Investiga ion, in my opinion dealt Oecnrled et::,.;
<br />the time, date and place and due to the cause(s) stated. (Signature and rale)
<br />Sarah Carstensen, Hall County Attorney
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />® YES ❑ NO
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED? '
<br />Not Applicable if 26a Is NO ❑ Yes ®NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 2, 2020
<br />
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