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<br />_STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA 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 />i)ATE €fSSUAN '
<br />LINCOLN, NEBRASKA
<br />202305047
<br />✓IGS^e...r? L, �i:.et /ae.
<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 />/
<br />ECE111 K
<br />1 DDENT'S NAME (dist, Middle, Last, Suffix)
<br />Wilms Heft Jacobson
<br />CERTIFICATE OF DEATH
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508-32,8457
<br />8b. FACILITY -
<br />8
<br />a
<br />6s.
<br />13
<br />•
<br />ME (If not institution, give street and number)
<br />Good Sa'm.altan Society -Grand Island Village
<br />Sc CITY OftTOWN OF DEATH (Include Zip Code)
<br />Grand Islaltd B$803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9c1. STREET AND NUMBER
<br />2826 Brentwood
<br />10a. MARITAL S
<br />❑ Marrlf
<br />9b. COUNTY
<br />Hall
<br />SAT' TIME OF DEATH ❑ Married', ❑ Never Married
<br />crated I1 Widowed [ i Divorced ❑ Unknown
<br />Sa. `AGE - Last Birthday'
<br />(Yrs.)
<br />93
<br />11. FATHERSNAME (Fi.
<br />Arnold RRaueit
<br />Middle, Last, Suffix)
<br />13. EVER IN U SARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />-3. DATE OF DEATH (Mo.
<br />June 23, 2022
<br />MOS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL ] Inpatient OTHER ® Nursing Horne/LTC ❑) esp)ee Facility
<br />0 ER/Outpatient ❑'Decedent's Homo
<br />DAYS
<br />HOURS
<br />MINS.
<br />6.DATE OF BIRTH Day, Yr.)
<br />November 9; 1.928 ..
<br />0 DOA 0 Other(Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68801 EE
<br />9g::Not* ov tows
<br />YES1 O o
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Eugene Elton Jacobson
<br />14a. INFORMANT -NAME
<br />Diane Jacobson
<br />2. MOTHER'S•NAME (First, Middle, ` Maiden Surname)
<br />Minnie Niemoth
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15. METHOD Q.F..:;DISPQSITION
<br />.Burial ]Donation
<br />O Cremation; Entombment
<br />❑ Rstnt?1ta1 Diller (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Katie. M. Smvdra
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />and Island City Cemetery
<br />17a. FIJNERAL#:iOME NA2!).E AND MA LINO ADDRESS (Street, City or Town, State)
<br />Ali faitths.itirleral'Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />160. LICENSE NO. '
<br />CITY / TOWN
<br />Grand Island
<br />16c. DATE (Mit , Day,:?'Yr.)
<br />June 27, 2922.
<br />CAUSE OF DEATH (See instructions and examples)
<br />Nebr`asl
<br />17b Zip C
<br />.88114
<br />18. PART I. 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 If necessary.
<br />IMMEDIATE CAUSE:
<br />a) cardiac arrest
<br />IMMEDtAT
<br />dleea$e or
<br />APPROXIMATE INTERVAL
<br />i.. onset to tteatI
<br />4 `Months
<br />44:41101r1„,p
<br />in death) DUE TO, OR ASA. CONSEQUENCE OF:
<br />sequentially list conaiSons, If b) COvid-19
<br />any, leadtng to ti : use I( I
<br />onlinsa
<br />Enter(149: UNDE)Rt;VING CAI,IBE
<br />•
<br />(disease or Injury' that Initiated
<br />the events reeul
<br />LAST
<br />In death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Failure to thrive
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d) Hypoxia
<br />18 MSART tat OTkIER SMGNMFICANT CONDITIONS -Conditions contributing to the death but not resuIUng to Lha underlying cause given in PART 1.
<br />24. IF:,gFEMALE
<br />❑ Not pfegnaitkwdlwt past _year
<br />❑ k.arLerltat9asdfaaatL,.'l
<br />❑ Not pregnara:,but pregnant within 42. days of death
<br />❑ Not pregnant," but pregnant 43 days to 1 year before death
<br />Unknown Ifere9nenf within the past year
<br />22a `t'iATE OF ISI:
<br />Y Into Day, V
<br />22d. INJURY AT WORK?
<br />DYES ".QNQ
<br />21a. MANNER OF DEATH
<br />Natural ❑ Nonrigid°
<br />0 AccIdeM 0 Pending Investigdtitn
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />o Duvet/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />onset to death
<br />4 Months
<br />onset tt rv7eatit
<br />4 Months..
<br />onset to death
<br />4 Months
<br />19. WAS MEDIC ILEXAM)NER
<br />OR CORONET# CONTACTED?
<br />® YES ❑ NO
<br />21c. WAS AN AUTOPSY: PE ,..ORMS t'
<br />❑ YES l\ ®(11#3
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 N :>
<br />22c. PLACE' OF INJURY -At 11ome,<farm, street, factory, office building, ci
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22r LOCATION OF INJURY«STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 23, 2022
<br />23b DATE SIGNED (Mo., Day, Yr.
<br />J24.2022
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />01:45 PM
<br />best of my Rnowiedge, death occurred at the time, date and place
<br />.8 eri6dae tetha eauae(s) stated. (signature and Title)
<br />Zachary W. Meyer, MD
<br />Ion site, eta (5f
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED,DEf
<br />24e. On the basis of examination and/or Investigation, in my opinion death bcotlrrerf aE
<br />the/line, date and place and due to the cause(s) stated. (signature and Tide) . .
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES EINO
<br />28. DID BACCO USE QQNTRIBUTE TO THE DEATH?
<br />YES NO ❑ PROBABLY 0 UNKNOWN
<br />27. NAME, TIT)E,ANI'#AI'JRESS OF CERTIFIER (Type or Print
<br />Zachary W: Meyer MD, 2116 W Faidiey #400, Box 9802, Grand Island', raska, 68803
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO AYES 'I
<br />28b. DATE FILED BY REGIST
<br />June 30, 2022
<br />t (Mo., Day, Yr.
<br />
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