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<br />STATE OF NEBRASKA )I
<br />•• WHEN TK!S' :' COPY CARRIES THE RAISED SEAL OF' THE STATE OF NEBRASKA,
<br />. CERT(FIES••; I HE 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.:0FFICE, WHICH IS THE LEGAL DEPOSITORY.FOR:.VITAL,REGORDS
<br />'l Ali OFISSUANCE
<br />6/9/2020
<br />UNCOLN, NEBRASKA
<br />202502369
<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 DECEDENTS NAME.AFirst, Middle, Last, Suffix)
<br />,lely 'Berrilce Jacobsen
<br />e. CITY AND'STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Broken Bow, Nebraska
<br />3 sobiA{ •SECi;i:Ft3''TY:NymBER
<br />506-56:5758:::
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />:w.
<br />a.:
<br />w..:
<br />O
<br />Qc
<br />. ?:EMMEDI.ATE:.L�'/111.SE� jFinti,
<br />_''disllilS:e or.roodittoii:i.�esttltit
<br />eb.FACItaTY-NAME (If ot.lnstitutlon, give street and number)
<br />Good Samaritan.Society-Grand Island Village
<br />1* CITY OR T01hI:N OF::DEATH (include Zip Code)
<br />G:(airld: Island' 6B.0.3`.
<br />ga. RESIDENCE -STATE"
<br />Nebraska
<br />9Q STREET.AND;NUN(BE?R:;:„
<br />407Tmbetllne.'!St.,. ':<
<br />9b.000NTY
<br />Hall
<br />73
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH..
<br />HCSPETAL 0:Inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />20 07"1;09
<br />3. DATE OF DFA"L51:4k
<br />May 29,
<br />6. DATE OF MR
<br />March 30, 1947._:::
<br />OTHER ® Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />111
<br />9f. ZIP CODE
<br />68803
<br />gq INS#t* CtT' t:ttalrr8
<br /><s 3 NO
<br />10a.'MARITAL STATUS AT TIME OF DEATH jz Married ❑ Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />1,:1 FArhi:ER'S-Ntl4t ;:(Fi.rst,, Middle, Lest, Suffix)
<br />Roberts..::` :Pracht:
<br />EVERS? Give dates. of service if Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />Der idea
<br />Cremation.' Entombtient
<br />0`ftetriQvaE .':l ]Other(Specify)
<br />1911.:NAME OF SPOUSE (Firth,
<br />Gerald Jacobsen
<br />14a. INFORMANT -NAME
<br />Gerald Jacobsen
<br />18a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />Middle, Last, Suffix) If wffe, give maiden norm(:;;
<br />12. MOTHERS -NAME (First, Middle, Malden Surname)
<br />Rosalie.. 'Fave
<br />16b. LICENSE NO.
<br />1.454
<br />14b. RELAUONSI'1W`TO DECE DEENT:i
<br />SPOUSE)
<br />16c. DATE (Mo., Day,,Yr.)
<br />June 3, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />••::SPATE ::
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Ail Faiths t tet*l'HOme, 2929 S. Locust Street, Grand Island, Nebraska..,
<br />CAUSE OF DEATH fSee instructions and examples)
<br />It, PART I. Enter the chain of events- -diseases, Injuries, or complicationsdhat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular horSatien without showing ttte etttnogy.'vO Not Abort IA iE. Enter only une cause un a tine. Add addit,onatines If necessary,
<br />IMMEDIATE CAUSE: -
<br />a) Respiratory Failure
<br />In death):::::' ..... ... DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, tt b) ALnS
<br />. Any, leading to the causs.teted
<br />E TO, OR AS A CONSEQUENCE OF:
<br />>EntgfTh Uf4DEtU X�tNO cAtISE :
<br />(dieeiisti rSt>irt)ur'y ilfal initiated'
<br />Inc events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />d)
<br />` 5. PART t OTHEER
<br />2G, IF FEMALE::..:.:: .:.....
<br />1 Net`pregnatfkwliit{ttipastyear
<br />0
<br />Pregnsrtt'at o tee of:iielltit' .:�:
<br />Net a ee'nant, set pia:gi pnt within 42 days of death
<br />0 Not pregnant, but pregnant 43 days, to 1 year before death
<br />.; .0 tjnknown If pt0gnant::w iIhin the past year
<br />N
<br />ONDITIONS.Conditions contributing to the death bu€not:reaulting in the underlying cause given in PART I.
<br />I2a« GATE 0
<br />J1 RY 61aRay, Yr.)
<br />22d. INJURY AT WORK?
<br />0 YES El No
<br />22f.:'e.i t.tio QF'
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0: tinverlOperator
<br />Pastonger
<br />• 0 pedestrian
<br />0 Other (Specify)
<br />1:Z�rCods .:::
<br />080015
<br />APPROICIMATeiTERVAL
<br />Dined to death.
<br />2 DavE>
<br />onset to death
<br />20 Months
<br />onset m death
<br />19. WAS MEDM:AL E AMENER::"'
<br />OR CORONERNTACT
<br />0' YES
<br />21c. WAS AN AU'1'OP$Y PERFORMED?. -
<br />YES fiaNO ,
<br />21d. WERE AUTOPSY FiNONGS"AVAii Al
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 .NO
<br />22c. PLACE OF INJURY4At.home, farm, street, factory, office building, constructio
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />NJURY;•••STREET 3 NUMBER, APT.NO.
<br />23e. DATE OF DEATH (Mo., Day, Yr.)
<br />May 29, 2020
<br />23b, DATE SIGNED (Mo., Day,Yr.)
<br />Maw:29;`2f20
<br />CITY/
<br />23c. TIME OF DEATH
<br />12:40 AM
<br />fo:1lla:ttetliai' my:liPo'lriMtg►, death occurred at the time, date and place
<br />acid due to:tiietaiiae(a) stated. (Signature and Title)
<br />seat J. Berg, MD
<br />25.. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />J`PROBABLY 0 UNKNOWN
<br />a7. NAME TITLE AND ADDRESS 00 CERTIFIER (Type of Pr;nt
<br />Isaac J. Berg, MD,729 North Custer Avenue, PO Box 2339,
<br />26s. REGISTRAR'S SIGNATURE
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED
<br />❑ YES 161 NO
<br />rand Island, Nebraska, 68803
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b, TIME OF DEATH
<br />ZI:P COt E
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e, On the Nd i of examination and/or investigation, in my Obi
<br />nlpt dsathaii....
<br />theurn t,:date and place and due to the cwd(s) stated. (Stgr)atbrs ale lde)
<br />26b. WAS CONSENT GRANTED?
<br />Not Appllcabe if 26e Is NO 4At'
<br />28b. DATE FILED BY REGlS
<br />June 2, 2020
<br />
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