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<br /><.11STATE OF NEBRASKA
<br />A40042.
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<br />WHEN THIS C01:)Y 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 />DITE OP ISSUANCE
<br />10/3/2023
<br />LINCOLN, NEBRASKA
<br />1
<br />1
<br />E.
<br />202305460
<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 />CERTIFICATE OF DEATH
<br />1. DECEDEffirSNAME: (First, Middle, Last, Suffix)
<br />Catherine K Scarborough
<br />4. Crr(AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Falls City, Nebraska
<br />7,200#4 sEDDROISitIpeEk
<br />lta, AGE • Last Birthday
<br />(Yrs.)
<br />73
<br />8b. FACILITY -NAME (It not Institution, give street and number)
<br />CHI Health St. Francis HMS
<br />8c.r.ITY OR TOWN OF BEATH (Include Zip Code)
<br />Grand Island:.:0883
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />itctiAilftErrottiipOusigistt212 2Otht
<br />:;:„:.:
<br />9b. COUNTY
<br />Hall
<br />5b UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />6c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />23 12116
<br />3. DATE OF DEATN1780.4h1teAr4
<br />August 29i::2923
<br />8. DATE OF BIRTH (Mo., Day,•Yr.)
<br />December 4, 1949
<br />841.: PLACE oF]ogATH;.:
<br />HOSPITAL Inpatient OTHER 0 Nursing Home/LTC
<br />ER/Ou patient 0 Decedent's Home
<br />0 DOA
<br />1iitiiiffiaNitAi:STATO.01:AT TIME OF DEATH Ea Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11.!A7•11EFC041• AME(Flost, Middle, Last, Suffix)
<br />11.8yEiii.iN1iS.: ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unit.) No
<br />18. METHOD OF DISPOSITION
<br />urlaigl!111:;1Q13.0ffittion
<br />cremation DEntombment
<br />0iii4ritsPecify)
<br />9c. GIN OR TOWN
<br />Grand Island
<br />0 Other (Specify)
<br />18d. COUNTY OF DEATH
<br />Hall
<br />8e. APT. NO.
<br />9f. ZIP CODE
<br />68801•
<br />0•Hoepide Faellity.
<br />tig. MVOs OFIYUmn's
<br />DA YES t3 •NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name
<br />Eugene Scarborough
<br />I12:15/IOTNER13.7NAME (First, Middle, Maiden Surname).,: d' :g:!..t...
<br />Maggie r 'Osborn
<br />14a. INFORMANT -NAME
<br />Joni Arnett
<br />16a. EMBALMER -SIGNATURE
<br />Tracey Dietz
<br />16b. LICENSE NO.
<br />1328
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Elmwood Cemetery St. Paul
<br />17a. FUNERAL !imp NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />:..Jacobsen4GriffertWav-Dietz Funeral Home, 411 0 Street PO Box 112, St. Paul Nebraska68$73
<br />CAUSE OF DEATH (See instructions and examples)
<br />11. PART I. Enter the chain of events- -diseases, Injuries, or complications.that directly caused the death. DO NOT enter terminal events such as cardiac sweet,
<br />respiratory arrest, or veMricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />• .
<br />iosseeskffi ckU$E Oinat a) pneumonia
<br />tiiiiiiase 0.40411010 ttiaaitiaa
<br />sequentially ilet Oondltions, if
<br />any, leading to the cause listed
<br />toi.i.sotott;.
<br />(dllitatilfOr irBOnitharlilltiated
<br />Inc events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)chronic obstructive pulmonary disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />•
<br />18, PART If. OTHER S1GNIFICANT CONDITIONS -Conditions contributing to the death but nett sesutfing in the underlying cause given in PART I.
<br />chronic respiratory failure,
<br />14b. RELATIONSHIP TO•DEOEDENT
<br />Daughter
<br />16c. DATE (Mo., Day, Yr.)
<br />August 20, 2023
<br />. .
<br />STATE . •
<br />• •
<br />Nebraska
<br />171). zjp..cook:
<br />APPROXIMATE INTERVAL
<br />onsetto d4411.1!
<br />onset tO death
<br />Years
<br />onset to death
<br />19. WAS MEOICAL EXAMINER
<br />OR CORONER CONTAcTED?
<br />DYES 51] NO
<br />20. IFFEMALE:
<br />pr�gnahtwithlnpayear
<br />q.PreftectofflottiMfidietif
<br />0 N0t)liegr140; btifyitetineM vAthin 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />El UnIcnown12pregitentwithin the past year
<br />22ai,DATEOFINjURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />YES 0 NO
<br />'
<br />210 MANNER OF DEATH
<br />Ea Natural plionilcide •• • • "
<br />o ent 0 itendIng Ifivestiyation
<br />0 Suicide 0.COUld not be date rMined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />0 Patten Of
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21e. WAS AN AUTOPSY PERFORMER?
<br />21d. WERE AUTOPS*EINOINGSAVALAOLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />22c. PLACE:OF INJURTAthOthei:fann, Street, factory, office building, construction aite0)40.18peo(ty..) pAi;
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22tacicAiilpsityttRy STREETa•NumsER,APTNO.-..:.:. . crrykrotfot
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 29, 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />September 7 2023
<br />23c. TIME OF DEATH
<br />05:00 PM
<br />2".ctnty knowledge, death occurred at the time, date and place
<br />*tthb
<br />anddetie"I° fo thecame(s) stated. (SIgnature and Title)
<br />Travis a Hageman, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />2413. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />SOcpfilltelftisis of extuninetion andlor Investigation, in my opinion diettY '
<br />Inc tlme date and place and due to the cause(s) stated. (lIgnsturritiaB2Ble)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES NO Q PROBABLY 0 UNKNOWN
<br />27. NAME,11TLE Ako ApoRass OF CERTIFIER (Type or Print
<br />Travis S. Haqemarl, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRARS SIGNATURE
<br />6/1-44_17
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />26b.WAS CONSENT GRANTED?:..:.
<br />Not Applicable if 26a Is NO ZITES
<br />NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />September 8, 2023
<br />0)
<br />N)
<br />
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