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STATE OF NEBRASKA
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<br />WHEN : THIS COPY . CARRIES THE RAISED SEAL ` OF THE STATE OF NEBRASKA, IT
<br />;CERTIFIES THE DOCUMENT BELOW TO BEAA TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />,RECORDSOFFICE, WHICH IS THE LEGAL DEPOSITORY FORVITALREGQRDS
<br />DATE OF ISSUANCE
<br />4/1/2021
<br />LINCOLN, NEBRASKA
<br />0411 &� �
<br />202AA0153 SE
<br />ISTANTATREGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />ECEDENTS-NAME<(Eirat Middle, Lsat, Suffix)
<br />Kathryne • Mae Johnson
<br />4. CITY AND:STATE:OOR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Shelton, Nebraska
<br />7 SociAL SLOURITrNIiMBER
<br />608 40 ;2880
<br />Sa.'AGE - Last Birthday
<br />(Yrea
<br />81
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />21 03901
<br />3. DATE OF ATH lien* Os y Xr.
<br />March 192021
<br />6. DATE OF maim (Mo. Dtiy, Yr.)
<br />June 8: 1..99....
<br />E
<br />sa:
<br />3
<br />8
<br />cQi
<br />Bb FA TY-NAME(if Of not Institution, give street and number)
<br />1220 W Koenig: St
<br />Sc.IwItY OR. TOWN OF .DEATH (ktclude zip Code)
<br />ralltl Island 688fl1
<br />9& RESIDENCE -STATE
<br />Nebraska
<br />9d: STREET AND 1404Eft
<br />1220W Koenig SC
<br />9b. COUNTY
<br />Hall
<br />Sa'PIACE OF DEATH
<br />HOSPITAL ❑(Inpatient
<br />Q ER/Outpatient
<br />❑ DOA
<br />10a :MARITAt:.STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11 FATHER'S +IAMB (First; Middle, Last, Suffix)
<br />:gTheitiffori VernonCosner
<br />13 EVER IN U'S ARMEE FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unit.) No
<br />16. METHOD OF DISPOSITION
<br />Q Bufial .::: r0
<br />Doi ation•
<br />Crematon 1_t Entombment
<br />}] Removal 0Other (Specify)
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />OTHER 0 Nursing Horne/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />8d COUNTY OF DEATH
<br />Hall
<br />Se. APT. NO.
<br />K. ZIP CODE
<br />68801.
<br />4g. •114$IDaprry UMI h.
<br />j'YES ONO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden tw,ia
<br />Harold Johnson
<br />1 12MOTHER`S-NAME (First, Middle, Maiden Surname);
<br />Laura Elizabeth Dally
<br />14a. INFORMANT.NAME
<br />Harold Johnson
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCA
<br />Colonial Chapel Cremation Center
<br />16b. LICENSE NO.
<br />17a.;PUNERA(..HOS...NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Livingston»Sondertnann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska .
<br />CITY I TOWN
<br />Lincoln
<br />CAUSE OF DEATH (Stein* u ions end examo(es1
<br />'IL PART I. Enter the chain of events- sdMMses, Injuries, or complications4hat directly caused the death. DO NOT enter terminal evdnts such as cardiac attest,
<br />respiratory arrest, or ventricular fibrillation without staining -Me etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Mees If d,e lliSt .
<br />IMMEDIATE CAUSE:
<br />IMREDiAtE CAUSE (Final a) Dementia
<br />ureses or condition resuhing�'
<br />In tenth(` ......
<br />Sequentially list conditions, if
<br />any, Lading to:the CiuM:ksted
<br />ottlhiee.
<br />Etit t':the
<br />Waage or )e(Uiy.thathOisted
<br />the *vents resulting in death)
<br />Last
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 PART U OCHER SIGNIFICANT CONDITIONS -Conditions contributing to the deatitbut not resuldny in thi underlying cause
<br />Hypertent(te HeartDisease, Congestive Heart Failure
<br />20.IFMMA
<br />0J` FELE::..
<br />NotPragnantw4.1.##%0.01k
<br />year
<br />4�
<br />Pregnant ar lrtw td deatlji�,
<br />`Norpregneht, but pregnant within42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before teeth
<br />. unbnosm, if:pr'e•
<br />gnsnt wititin the past year •
<br />21a. MANNER OF DEATH
<br />Natural HomfClda
<br />0 Accident © Pending invesaga ion
<br />0 Suicide Q Could not be determined
<br />PARTE
<br />24b. IF TRANSPORTATION INJURY
<br />irIvor/Operator
<br />©Pasmg.r
<br />.,: Pedestrian
<br />0 Other (Specify)
<br />14b. RELATIONSHIP Too
<br />Spouse
<br />166. DATE::(Mo., Day, Yr.)..:,:;.
<br />March 28 2021;:
<br />STATE
<br />Nebraska
<br />APPROXIMATE arreRYAL
<br />onset to*loth
<br />Mor►tb
<br />onset to death
<br />onset to death
<br />f: WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?` :s
<br />E7 YEs ® NO
<br />21c. WAS AN AUTOPSY PERFORMED
<br />❑ YES Q NO.:
<br />21d. WERE AUTOPSY -FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OP MATH?
<br />Q Yes O.. NO
<br />22e. DATE OFIINJURY (Mo, Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF lNJURY•At home:; famt,;street, factory, office building, construction
<br />22d. INJURY AT WORK?
<br />❑ YES :❑NO::...
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />LOCATION Of p(JUrtY STREET & NUMBER, APT.NO.
<br />CITYITOWN
<br />STATE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 19, 2021
<br />23b DATE SIGNED (Mo., Day, Yr.)
<br />(V[arch 22:.2021
<br />23c. TIME OF DEATH
<br />10:58 AM
<br />T*.ttabast tr y knowledge, death occurred at the time, date and place
<br />and due to the causes) Stated. (Signature and Title)
<br />Chad Vieth, MD
<br />26.: D(D::7OBACCO. UBE.GONTRIBUTE TO THE DEATH?
<br />PROBABLY 0 UNKNOWN
<br />27:',NAHIEVIITEE APiif3 ADDRESS OF CERTIFIEFF(Type or Print
<br />Chad Vieth MIS; 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803:
<br />E
<br />„ 24c, PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TUNE PRONOUNCED DEAD
<br />24e. DATE SIGNED (Mo., Day, Yr.)
<br />TIME OF DEATH
<br />24e. On *Oasis of examination andfor investigation, in my opinion ate aceu. Pi
<br />the Ones, date and pine and dun to thecausefs) stated. ( and Thio)
<br />26a. HAS ORGAN OR TISSUE DONATION: BEEN CONSIDERED?
<br />Q YES NO
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. WAS CONSENT GRANTED?...
<br />Not Applicable If 26a is
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 25, 2021
<br />
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