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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 OFISSUANCE
<br />9/28/2021
<br />LINCOLN, NEBRASKA
<br />202306109`
<br />E
<br />at
<br />'xS
<br />a
<br />E.
<br />0 O
<br />SARAH BOHNENKAMP T'
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />1. DECEDENTS NAME (First, Middle, Last, Suffix)
<br />Deborah.; K Ove -field
<br />4. CITY AND STATE OR
<br />Dayton, Ohi
<br />CERTIFICATE OF DEATH
<br />RRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />70SOCALsogdATY4UMBER
<br />28554 7G17
<br />5a. AGE - Last Birthday•
<br />(Yrs.)
<br />8b.'FACILITY=NAME flf not Institution, give street and number)
<br />2023 Lamar Ave
<br />CITY,OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 683
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d.STREET AND NUMBER
<br />zoz3 Lari•;iar Ave
<br />9b. COUNTY
<br />Hall
<br />70
<br />5b; UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />21 12407
<br />3. DATE OF DEATH:(Mo„ DayxYr.):
<br />Septembet 17, 2021
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑Inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />10a,' MARITAL:; STATUS AT TIME OF DEATH RI Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11, FATHER'S-ftiAME (First, Middle, Last, Suffix)
<br />Harty F Snyder
<br />13. EVER iN U,8 ARMED FORCES? Give dates of serviced Yes.
<br />(Yes, No, or Unk.) No
<br />15.r �METHOD OF DISPOSITION
<br />Burial [ Donat)onbm
<br />Cramatioii ❑ Erxtotnant
<br />❑Removal ❑Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MIN
<br />6. DATE OF BIRTH (Mo Day;::
<br />November 25, 1950
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />18d. COUNTY OF DEATH
<br />Hall
<br />90. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If
<br />George J Overfield Jr
<br />1 12. MOTHER'S -NAME (First, Middle,
<br />Adalberto M Ryan
<br />14a. INFORMANT -NAME
<br />George J Overfield Jr
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION . I'
<br />Westlawn Memorial Park Crematory
<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 />Hospice PaciUty
<br />8c.
<br />8g• INsioE c r LIM
<br />[ vEs ❑ N
<br />e maiden name
<br />Maiden Sumame)
<br />14b. RELATIONSHIP TODECEDENT.
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)':
<br />September 21,, 202
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chainof 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 Zine. Add additional lines 8 necessary.:.
<br />IMMEDIATE CAUSE:
<br />a)Adenocarcinoma of Lungs
<br />iM..MEDtATE CAUSE IPinal
<br />disease er condition resualate
<br />M death): <.
<br />Sequentially lint conditlot
<br />any, leading to the Cause listed
<br />Enter ths UN0ti R viNOCAtise
<br />(dlasase orin)uiythattnhiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />STATI:
<br />Nebraska
<br />17b. Zip Code::
<br />68803! ....
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />4 YeirS
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />1fk:PARTi1 OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Metastasis If Lung Cancer
<br />20. I) FEMALE: ;
<br />'.:Not pregnantwlthin p
<br />•
<br />Pregnanttime of dea4h.
<br />❑:<Nol 0.0 lit, but Pregnant within 42 days of death
<br />0 Net pregnant, but pregnant 43 days to 1 year before death
<br />nn: Unknown 11pregnant within the past year
<br />226,.DATEpFINJURY (M0 , Day, Yr.)
<br />22d. INJURY AT'WORK?
<br />YES r3 NO
<br />21a. MANNER OF DEATH
<br />Ea Natural 0 Homicide
<br />❑ Accident ❑ Pending investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />0 Other (Specly)
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />21o. WAS AN AUTOPSY PERFORME
<br />❑ YES EU NO
<br />21d. WERE AUTOPSY FINDINGS AVA1LASLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES ❑NO.
<br />22c. PLACE! OF INJURY -At home, farm, Street, factory, office building, construction site, iota (Spec
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION: OF iN,1URY STREET & NUMBER, APT:NO.'
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 17,2021
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />September 20, 2021
<br />23c. TIME OF DEATH
<br />12:41 AM
<br />lit To the best of my knowledge, death occurred at the time, date and place
<br />end due tattle cause(s) stated. (Signature and Title)
<br />Douglas Herbek, MD
<br />28. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES ❑ NO ❑ PROBABLY ® UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />)y codi.
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />2411.11ME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On **Oasis of examination and/or Investigation, in my opinion dead) Otcurret at
<br />ahs time, date and place and due to the cause(s) stated. (signature Arid Tiae)
<br />28a. HAS QRGAN,OR TISSUE DONATION. BEEN CONSIDERED?
<br />❑ YESI 1 NO
<br />27, NAME TITt,E AA10 At1bRESS OF CERTIFIER (Type or Print
<br />C)ouolas.lerbei€, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 6a803'
<br />28a. REGISTRAR'S SIGNATURE j
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO 0 YES
<br />28b. DATE FILED SY REGISTRAR (Mo., Day, Yr.)
<br />September 20, 2021
<br />
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