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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />,SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD-GNFILE WITH
<br />fHE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS seeTlON. WHICH IS
<br />
<br />:::;:~;~::EfTORY FOR WTAL RECOROS.M"rf-';_~_~
<br />MAR 0 6 2 JJvw,v~'w-s: qQQPER -
<br />. 006 2 0 0 6 0 2 0 9 8 ASS/STANrsJATE REGlstFtAR
<br />'L1NCOLN, NEBRASKA HEAL TH ANDHu.~4rJ.c~,!/JVIC9S
<br />
<br />~
<br />
<br />
<br />STA. J"E OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCEAN. D. SUJ:PORT -0 6 2..2... 0 9 3
<br />_ CERTIFICATE OF DEATH __. __ _ _ _
<br />
<br />(First. Middle. Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo" Dey, Yr,)
<br />Sharon Rose Johnson Fema~e February 23, 2006
<br />
<br />4. CITY AND STATE O~~~RRITORY. OR FOREIGN COUNTRY OF BIRTHTa, ~~E.La't BlrtMsy 5b. UNDER 1 YEAR 5c_ UNDER 1 DAY 6, DATE OF BIRTH (Mo., Dsy, Yr,)
<br />(Yrs.) MOS. PAYS HOURS MINS.
<br />Grand Island, Nebraska 62 September 28,1943
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />505-54-4834
<br />
<br />es. PLACE OF DEATH
<br />~; 0 Inpallent
<br />
<br />Qlli&8: IX Nursing Home/LTC U Hospice Facility
<br />
<br />eb. FACILlTY.NAME (If nOI In,lItullon, give Ilreet and number)
<br />
<br />o ER/Outpatlent
<br />
<br />o C.cedenl'. Home
<br />
<br />Francis Skilled Care Nursing
<br />
<br />19b' COUNTY
<br />Hall
<br />
<br />o CO\ 0 Other (Speoily)_
<br />
<br />I ed, COUNTY OF DEATH
<br />Hall
<br />
<br />~CITY. OR TOWN
<br />Grand Island
<br />
<br />_.._~~AP~l.~i;~~~ ____.
<br />
<br />fOb, NAME OF SPOUSE (First, Middle. Last, Sulllx) If wifa. glvI maiden nama.
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />DI YES U NO
<br />
<br />RD
<br />
<br />lOa. MARITAL STATUS ATTIME OF DEATH ~Ma"led 0 Never Merrlad
<br />
<br />o Divorced U Unknown
<br />
<br />Jimmy Johnson
<br />
<br />Middle.
<br />
<br />La't. Sulllx)
<br />Nienhueser
<br />
<br />12, MOTHER'S.NAME (First,
<br />Maxine
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />Hein
<br />
<br />14b_ RELATIONSHIP TO DECEDENT
<br />Husband
<br />
<br />leb. LICENSE NO.
<br />1092
<br />
<br />16c. DATE (Mo.. Day. Yr. )
<br />Feb 28, 2006
<br />
<br />CITY /TOWN
<br />
<br />STATE
<br />
<br />Grand Island
<br />
<br />NE
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<br />Ie. PART J. Enta, tha ~lMm"diaaasas, Injurie.. 0' compllcatlons"lhat directly caused the daath. DO NOT enler tarmlnalevents such a. cardiac a.,e.l,
<br />'asplratory attest, Or ventrlculer Ub,lIlatlon without showing the etiology. DO NOT ABBREVIAT~_ ~nter only ona cauae on ellne. Add additional line. II rleee.sa,y.
<br />IMMEDIATE CAUSE:
<br />
<br />on.ello daalh
<br />
<br />IMMEDIATE CAUSE (Final
<br />di..... or condlllon '"ultlng
<br />in death)
<br />
<br />Sequent/elly ust conditio"" If (b)
<br />any.l.adlng loth. .auseUsted -'DUE TO, OR AS A CONSEQUENCE OF'
<br />on linea.
<br />Ente'lh/r UNDERLYING CAUSE
<br />(dleee.. or Injury that Inlllalad (c)
<br />the events ..eulllng In death) _ DUE n3. OR AS A CONSEQUENCE OF:
<br />lASr
<br />
<br />(a)
<br />
<br />6-~(Jlr,~
<br />
<br />G'u,VlCe..-
<br />
<br />,All UI1/I4_J
<br />
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />onset to death
<br />
<br />(11)
<br />
<br />I
<br />I onset to death
<br />I
<br />
<br />
<br />- 19IWASMEPICALEX!iMIN~R
<br />OR CORONER CONTACTED?
<br />o YES IX NO
<br />2f c, WAS AN AUTOPSY PERFORMED?
<br />
<br />DYES lXNO
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS.Conditlon. contributing to tho death bUI nol ..suiting In tha underlying cau,. given In PART I.
<br />
<br />20, IF FEMALE: 210. MANNER OF DEATH 21b.IFTRANSPORTATION INJURY
<br />!Xl NOI pregnant within pa.t year DlNelural 0 Homlclda 0 Drlver/Operatcr
<br />
<br />o pragnent at time of death 0 AccldantO Pending Inv..tl9atlon 0 Passenga,
<br />
<br />o Not pregnanl. bUI p'egnant within 42 day. 01 death q Suicide 0 Could nol be detarmlnad 0 Pede.\i1an 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o Not pregnant, bUI p'egnanl43 days fo 1 year before dealh 0 Other (Speolfy) COMPLETE CAUS~ OF DEATH?
<br />o Unknown If pragnant within Ihe past year 0 YES U NO
<br />
<br />~ATE OF INJURY (Mo_, De,::~TIME OF lNJUR: 220. PLACE OF INJURY.At home. farm. .treel, laclo,y. offica building, construction site. etc,-(Sp;c~-'
<br />
<br />
<br />22d.INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />Cl YES 0 NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER. APT. NO.
<br />
<br />CrrY/TOWN
<br />
<br />STilTE
<br />
<br />ZIP CODE
<br />
<br />",Hj
<br />.a!3iil
<br />lis~
<br />
<br />e ."j>: Z
<br />8ff)"O
<br />1l~5
<br />~II:O
<br />81;
<br />
<br />25. DID TOBACCO USE CONTRIBUTETO-TME-CEJI; ? 2ea, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />o YES M NO 0 PROBABLY 0 UNKNOWN 0 YES ~ NO
<br />~NAM~Ni:iADDRESS OF CERTIFIER (PHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Jeffrey K. King M.D. 729 N. Custer AV, Grand Island, NE 68803
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<br />24a. DATE SIGNED (Mo., Day, y,,)
<br />
<br />24b_ TIME OF OEATH
<br />
<br />m
<br />
<br />m
<br />
<br />24C_ PRONOUNCED DEAD (Mo_. Dey. Yr.) 24d_ TIME PRONOUNCED DEAD
<br />m
<br />
<br />249, On the basis of examination andfor investlgatlon, ill my opinion death occurred at
<br />the time. dete and place and due 10 !h. cause(.) Slated, (Signa lure and Title) 'f'
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />Not Applicable it 2ea i, NO 0 YES IX NO
<br />
<br />2ea. R~GISTRAR'S SIGNATURE
<br />
<br />
<br />2eb. DATE FILED BY REGISTRAR (Mo" Day. Yr.)
<br />
<br />MAR 2 2006
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