|
ISTITIOW
<br />friAlgrIrr
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A 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 />MOOR
<br />Ol1aro=1 QI dJ6it tit Mt@Mit
<br />STATE OF NEBRASKA
<br />a. rttl<61111fftlat�. z. utilrrerpravv l�_.
<br />ice,°aal(f14t7,(¢f iC'P
<br />ai3lyeeAraa+ave>i:548991WFttlssP ;Ftitti!iyadaa?
<br />DATE' OFISSUANE
<br />LINCOLN, NEBRASKA
<br />202401601
<br />SARAH BOHNEN1 A'
<br />ASSISTANT STATE REGISTRA
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (Firsts Middle, Last, Suffix)
<br />Onnexh ;Melvin Johnson
<br />4.'C(TY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hershey. Nebraska
<br />7. StlCiees I RITYNuMBER
<br />Sf5.4S-8999
<br />tIM AGE - Laat Blrtltday
<br />(Yrs.)
<br />84
<br />1
<br />lib. P'ACtLITY-NAME (If npt lnstitudwt, give street and number)
<br />2435 Del Monte Av
<br />ue,,
<br />8c. G17Y OR TCI V t OF'DEATH (Include Zip Code)
<br />Grand tstand 68803
<br />Ss.RESIDENCE.STATE
<br />Nebraska
<br />9d: STREET ASD NUMBER
<br />2435 Dei Monte Avenue
<br />9b. COUNTY
<br />Hall
<br />5bUNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a PLACE OF DEATH
<br />•
<br />HOWL ❑ Inpatient
<br />0 ERiOu patient
<br />❑ DOA
<br />TOIL MARITAL STATUS AT. TIME OF DEATH Ea Married 0 Never Married
<br />0 Marded, but separated 0 Widowed 0 Divorced 0 Unknown
<br />1 EATHER'SiNANIE (Fl;pt Middle, Last, Suffix)
<br />Kenneth Johnsen
<br />13 :EVER IN U $:ARMED ORCEB?
<br />(Yes, No, or Unk.) No
<br />5.„910OFDISPOSITION
<br />Burial € ❑Donation
<br />{'Cremedoll Q Entombment
<br />❑ Removal ❑ Other.(Spedfy),
<br />Give dates of service N Yes.
<br />9c. CITY OR'TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH(Mb DBy, Yr:)
<br />May 29, 2023 .
<br />8. DATE OF BIRTH (Mo., DaYar:)
<br />November,1938
<br />OTHER 0 Nursing Home/LTC
<br />Decedent's Hi
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />10 404 LTS
<br />t2.YE$ D. tla
<br />lab. NAME OF SPOUSE (FItat. Middle, Lest, Suffix) If wife, give maiden name.
<br />Barbara Jean Dormann
<br />12. MOTHER'S -NAME (First, Middle,
<br />Marv': Davis
<br />14s. INFORMANT -NAME
<br />Barbara Jean Johnson
<br />16a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />FUNERAL;HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />AH Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebras
<br />CAUSE OF DEATH (Seeln
<br />lab. LICENSE NO.
<br />1397
<br />CITY / TOWN
<br />Grand Island
<br />ucllons and examples)
<br />1s, PART L Enterthe clWit of events- dlsissns, Injuries, or comp11ca6ons4hat directly caused the death. DO NOT enter terminal events such as cantles arrest,
<br />respiratory arrest; orventricWar fibillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one ane. Add additional liner N necessary..
<br />IMMEDIATE CAUSE:
<br />) Metabolic coma
<br />ga RELATIONSHIP
<br />Wife
<br />18c. DATE (Mo,,:
<br />June 2, ,2023
<br />IMM80911. CAt/SE (FAui
<br />dt*eus or rondltto1 roseetw>e
<br />$aqusntlWy len cendtllons, Ir'.
<br />any,.:,Naend to the. cauea $ttrd
<br />(die ua er brkny ibat
<br />me events rsaulhnp in du
<br />LAST
<br />DUE TO, OR A CONSEQUENCE OF:
<br />Dysphagia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)Pancreatic cancer
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />APPROXIMATE -INTERVAL
<br />eerasttode8th
<br />onset Loa
<br />Days
<br />f8. PART 11 OTHER SIGNIFICANT CQNDMONS-Conditions contrlbudng to the death but not resulting to the underlying cause given In PART 1.
<br />Stnlctn/e hydronephrosls
<br />❑ i!regl
<br />0'jrW preaseM wrthht 42 days of death .
<br />❑ Nat pregnant! but pregnant 42 days to 1 year before n Bath
<br />sri�n Unitnown (f pfegnant. wines the put your
<br />22r :DATE OF IN:iURY (NIC„ Day, Yr.)
<br />AT'WORK?
<br />YES ❑ NO
<br />2®a . NMANNER OF PHD.ndinomATgH
<br />❑ Accident e
<br />❑ 1
<br />see
<br />❑dbtmans
<br />22b. TIME OF INJURY
<br />22c. PLACE OF I
<br />1. DESCRIBE NOW INJURY OCCURRED
<br />2 LOCATION: OF INJURY;rSTREET
<br />NUMBER, APT.NO.
<br />23a. DATE °PDEATH (Mo., Day, Yr.)
<br />May 29 2023,
<br />} 23b. DATE SIGNED (Mo., Day, Yr.)
<br />rag Mev 3£) 2023
<br />CITYFTOWN"
<br />23c. TIME OF DEATH
<br />03:10 AM
<br />**Todd #!U baator my knowiedee,death occurred at t e time, date and place
<br />and: dW to the uags) stated. (Signature and Title)
<br />Jessica M. Hatch, MD
<br />UR
<br />21b. IF TRANSPORTATION INJURY
<br />Ddvr/Operator
<br />:❑ Pdeasnger
<br />❑ Pedestrian
<br />0 Omer (Specify)
<br />21c. WAS AN *1
<br />❑YES 1
<br />21d. WERE AUTCIPSTY F1NOINos AVAILABLE
<br />TO COMPLETE; CAUSE OF DEATH?
<br />❑ YES 0 N
<br />d home, farm, street, factory, office building, construction sito,el . (Spard r}
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME
<br />zip;CODE
<br />24e. On the bgsts of examination andror investigation, In my spied* dfetb acted
<br />tie MtiM deb and place and due to the causes) stated. (SilMaWte MOMS)
<br />is
<br />2B Div TOBACOO USE CONTRIBUTE TO THE DEATH? ' 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />vies ❑ NO ❑ PROBABLY E: UNKNOWN 0 YES ®NO
<br />2i NAME, TiTLE;ANDADDRESS OF CERTIFIER (Type or Print
<br />JOSStaa M ; Hatch, •MD, 6201 East 25th St, Kearney, Nebraska, 68847',< .
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable H 28s Is NO ' ' ❑ Yes
<br />0
<br />28b. DATE FILED BY REGISTRAR!+
<br />June 6, 2023
<br />
|