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<br />.4',/••' .0 '
<br />. ' ........„. - • - • .
<br />MSE:COPY CARRIES THE RAISEG!1..;04,L.!! gfH7tit..g :STATE OF NEBRASKA, IT ..
<br />CERTIRESETHE DOCUMENT BELOW TO BEV.A TRUE'awrIOF THE ORIGINAL RECORD
<br />•
<br />• • ON FILE WITH THE • NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL •
<br />..:::figposoSPFRCE, WHICH IS THE LEGAL DEPOSITORYfOR,,KAL,,,BECORDS
<br />„ .•
<br />'E•;,1214•1* QFISSUANCE
<br />.12/23/2016 ••2 0 '2 3 03 2 6'1 . ASSISTANT STATE REGISTOAR .
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />•
<br />LINcoM
<br />NEBRASKA
<br />STANLEY S. PER
<br />vionilOW
<br />1. DECEDENTS -NAME (tiirst, • Middle, Last, Suffix)
<br />Dorothy Lucille Johnson
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />4;ici1:qp.:frr,40 QE TowtToRy, Ott FOREIGN COUNTRY OF BIRTH
<br />GreetattdatibkNibraiska
<br />7. SOCIAL. SECURITY NUMBER
<br />skAoq!it_totptitdttoai
<br />RE'
<br />AP.
<br />92k!r-1!
<br />101 FROLITi-Nmie gram 11461%100n, give street and number)
<br />Good Samaritan Society -Crane Meadows
<br />g 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />88. LINDER.1 YEAR
<br />2. SEX
<br />Female
<br />6c. UNDER 1 DAY
<br />MOS
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />Eft/Ontp)ffient
<br />TO 664
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (MO., Day, 14.4
<br />December 14, 2016
<br />6. DATE of eitatit1:#4DeyW
<br />Februaint 13. 1924
<br />OTHER 0 Nursing Horne/LTC • R.Hoepce Foixy
<br />0 Decedent's Home ..
<br />Eta Other (TiltefiliYASSISTElitHiffftit'..!!'„:„:',W
<br />8d. COUNTY OF DEATH
<br />Hail
<br />RPO*4901StOil:::':!!!
<br />9d. stizE*‘YANOVUMBER
<br />5l4West 7th Street
<br />4 -aa. MARTTAL sTATIApAfmte!OF DEATH 0Married 0 Never Married
<br />0 Min100, but sep,ra,1,
<br />11, FATHEFtwooiE,i0ott; 1Alddle, Last, Suffix)
<br />• Carl Switzer
<br />9b. COUNTY
<br />Hall
<br />a"ocr.r..yormwo...,
<br />e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. CflYtIMITS
<br />SI YES 0 NO
<br />*:10b. NAME .Off$POUSE:(Fip$44:,:Middle, Last, Suffix) ff wife, give maiden nanot::.
<br />42. MOTHER'SNAME (First, Middle, Maiden Sutoame)
<br />Lena Osterloh
<br />eyERINU.SARNIEDif9RCES? Give dates of service If Yes.
<br />N&'•:dr 00.0 ND•
<br />i10. seletkib#000011* •
<br />Donation.,'
<br />0 Cremation 0 Entombment
<br />:RfilfiOYai 08.iotty)
<br />14a. INFORMANT -NAME
<br />Sharon Giannakocoulos
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCoy
<br />14b. LICENSE NO.
<br />1191
<br />14b. RetAlsoilpe!:79
<br />Dauuhter
<br />16c. DATE (111o4t*Ir.);$:,:,
<br />December 26.'2016 •
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />CITY I TOWN
<br />Grand Island
<br />. . STATE . .
<br />I4411V091141W
<br />ytit.:Oittmot ioprot.:4mg:sulo MA LINO ADDRESS (Street, City or Town, State •
<br />Apfetfunetitil Home. 1123 W. 2nd. Grand Island. Nebraska
<br />11b4tp.
<br />CAUSE OF DEATH (See Instruct)9np aid examples)
<br />polopt Wier thiiphaingfinkkits- -diseases, injuries, or complications -that directly caueeRg*Miatiti00 NGT enter *ants such as cardiac arrest,
<br />:•:„
<br />kelltriCtiler fibrillation without showing the etiology. DO NOT ABEREIENTE. pot only 0.MMftipe •:06* UOL Add addklonal lines if necessary.
<br />whisowis CAUSE tFiest
<br />disease or condition resulting
<br />any;•..f.eadmakethe..muselteMd.•„:".•
<br />•••••-••• •
<br />•, •.
<br />. '
<br />Enter the UNDERLYING CAUSE
<br />011sesti5Mittjury Mat *Elated
<br />a) Respiratory Failure
<br />DUE TO, OR AS A CONSEQUENCE OF: :.• .•,•-
<br />blCarcinoma Unknown Primary Suspept:4un0::::!!:
<br />APPMOXMEIINT...VAL
<br />onset to4000
<br /><1 Week.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />•d)
<br />.••
<br />moat to death
<br />•
<br />1& PART 0. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART L
<br />Dementia
<br />20. 10#4M4t*:.:,!!
<br />§ 0 Pregnantat lime of death
<br />MRkkettI`witike 42 days of death
<br />OtO4Wittit+1 days to 1 year before death
<br />0AOM#04i*MOMInt'49g*UktkelltYW
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />• ..... • ...' • ..... •
<br />22*LIN4*rx0-0**:0,
<br />21a. MANNER OFDEATH
<br />51:1 Naturat 0 HInnitlde
<br />0 Accident
<br />0 Suicide
<br />22b. TIME OF INJURY
<br />0 Pending Investigation
<br />070ulp110t bnpateiritiiner111111
<br />21_,_k,i1F3RANSPORTATION
<br />Otit.firerfOperator •
<br />0 Passenger
<br />pedestrian
<br />911otil8peeffy)
<br />INJURY
<br />19. was MEDICAL EXAMINER
<br />OR C°/61:#.0ft C914TACTfrP9
<br />YES 100 !!!!!!
<br />21e. WAS AN AUTOPSYVARIFORIfiff.cfk.:.
<br />"•••••
<br />OYES JNO
<br />21d. WERE AUTOPEXPINDOSS.AVARARLE
<br />TO COMPLETE dAtifit0F.DEATH?:;
<br />YES ONo
<br />22e. PLACE OF INJURY -At home, farm, street, factory, office building, construction elle, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />0A3 ORDEATH (Mo., Day, Yr.)
<br />tibiietiiii!ii44,:2016.: • .•
<br />230. DATE arotiao (Mo., Day, Yr.)
<br />pe9erribir 15. 2016
<br />To the best of my knowtedge, death occurred et the time, date and place
<br />and due to the cause(s) stated (Signature and TRI*
<br />23e. TIME OF DEATH
<br />02:30 AM
<br />Jennifer arn, MD'
<br />25. DI.DIVISACOP USg1;4201RIBUTE TO THE DEATH?
<br />PROBABLY 0 UNKNOWN
<br />240. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF MTV
<br />:2dc. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED ..:„
<br />24e. On the basis of examination mW or Investigation, In My opinion deatheccunidei
<br />the time, date and place and due to the cane** stated. Illignatme and IMO
<br />26a. HAS ORGAN OR TISSUE DONATION
<br />DEW CONSIDERED?
<br />26b. WAS CONSENT GRANT MN
<br />Not Applicable If 26.1 Is No • 'Ski
<br />21. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jeffnifer LA3rown.,..MD.; 729 North Custer Avenue, Grand laland,„„Nebraaka,..66803:.,.:..
<br />• , ,
<br />2Sb. DATE FILED BY REGISTRAIMM0.*12o4Yiiiiiiiiil
<br />December 19, 2016 11!iilligi!."
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