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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANDHl)JII~N SERVICES
<br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGIN#'RE~~~W1TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST4tJS.,....1!~1!fs!..&_l/f!'Ik?f1IS
<br />
<br />
<br />::;;:::~:::::~TORY FOR VI2TALOROEC70RODS3" 389 j~. .~j.~~\~-J~:~:~~\
<br />, l JJT'Y4tANtE"$.=~O()Pef!=,
<br />SEP 3 0 2005 AsSIsTANT STATE RErilS!ilAf!
<br />LINCOLN, NEBRASKA HEAltH A"NP HU""~'l$EfJ'I1C1f?
<br />---~,;.J.-
<br />-~~.~~...
<br />
<br />
<br />ST.. ATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HU...MAN.SERVICESRNANCE'AN!J.._SLJf>.fflR.' Tn c. 1 0 ~7 7 0
<br />-----"_______~ERTIFICATE OF pEATH ..-~~__~~_
<br />
<br />1. D~C~D~NT'S.NAM~ (First. Middle, Last, Suffix) 2, SEX 3. DATE OF D~ATH (MD., Day, Yr,)
<br />
<br />- Pamel~ __M~ -------Lohans~_ _ _ FemC!J,e ,September f_h....LQQ2..
<br />4, CITY AND STAT~ OR TERRITORY, OR FOREIGN COUNTRY OF 81RTH r' ",.c., ''''"'J '" ""'" "" '". ""'" M' ; M"" '<om "0. ..,. ,,' .
<br />(Yrs) MOS r DAYS HOU~. _'. MINi;'
<br />Spaldir:g, Nebraska __ 5~__ _I Novemb~r 16_,_ 1954_
<br />
<br />7 SOCIAL SECURITY NUMOER Ia PLACE OF DEATH
<br />~7:-78-7898 _ ____ ____ _ ~L Olnpallent QlliER; 0 N",slngHoma/LTC OHosplcefacilily
<br />
<br />8b, FACILITY-l'fAM~ (If not Institution. give SIr.ot and number) 0 ER/Outpallent !llI Deced.nt's Home
<br />
<br />4409 Stoneridge Path 0 [X)\ OOther(Sp.clfy)_____
<br />
<br />8c CITY OR TOWN OF DEATH (Include ZIP Code) - - - - 'I~d COUNTVOFDEAT~--- -- -
<br />
<br />Grand Islan~68801 ___ __ Hall ______
<br />9. RESIDENCE-STATE -r- 9M:OUNTY ~9.;:cITV OR TOWN
<br />
<br />Nebraska ~Hall ___~Grand Island
<br />9d,STR~ETANDNUMB~----- -- - ----r.i..APT,NO... 9f'ZIPCOD~.- '~9..'-INSIDECIT.V LIMITS
<br />
<br />44...Q2......Stone;:idge]ath ---_~J_ _ 68~~_~9 YES Xl NO
<br />10.. MARITAL STATUS AT TIME OF DEATH ~ Married [.J Never M.rrled lOb. NAME OF SPOUSE (Firsf, Middle, Lasl, SUfllx) If wife, glv. m.lden nam.,
<br />
<br />o Married, but sopareted OWidowed [.J Divorced 0 Unknown Ronald L. Johansen
<br />
<br />11, FATHER"S-NAME -(F~-------;;;;;;-dIO~ L.sl, s~iIlX) . J2' MO. TH~R-;S-N.AM~ (F1r';,---- Middlo,
<br />
<br />,_~ii.ude _,.__-----Y.~ncent St:r~__ ____ Marg~!:~_ Mary__
<br />13. ~VER IN U.S. ARMED FORCES? Give d.les of service if yes. He, INFORMANT-NAME
<br />
<br />___ Ronald .L. Johans~_n _
<br />16. EMBALMER-SIGNATURE "~~NSE NO
<br />
<br />No"t Embalmed --__~L_____
<br />16d, CEMETERY, CREMATORY OR OTH~R LOCATION CITY !TOWN
<br />
<br />Maidan Surname)
<br />
<br />J~onovaIl______
<br />14b. RELATlDNSHIP TO D~CEDENT
<br />
<br />Husband
<br />--"--"'.--,..
<br />
<br />OSurial
<br />
<br />o Donation
<br />
<br />16c, DAT~ (Mo" Day, Yr, )
<br />
<br />Se tember~2905
<br />STATE
<br />
<br />\1IJ Cromatlon 0 ~nlombmenl
<br />
<br />o Romov.1 0 Olher (Spoclly)
<br />
<br />_ Westlawn ~remato~
<br />17e, FUNERAL HOM~ NAME AND MAILING ADDRESS (Slreol, Clly or Town, St.te)
<br />Livin ston-Sondermann F.H., 601 N. Webb Rd., Grand Island, Nebraska
<br />
<br />-~-,-,._.",_.~--
<br />
<br />Grand Island,
<br />
<br />18. PART I.l::.nler the c.haj.n,21,~--diseases, injuries, or cmnplicationS--lt1at directly caused the death. DO NOT enter terminal eVents such as cardiac arrest,
<br />.L resplr.tory .rrosl. or ventricular flbrlll.lion without showing Ih. etiology, DO NOT A8BREVIATE, ~nter only one causa on a line, Add .ddllionellln.s If nocoss.ry.
<br />
<br />Sequentially list condlllons, If (b)
<br />any.I..ding loth.ceu..llsted DUE TO, OR AS'A- cONs~6ijENCE 01":-----.-..
<br />on line a.
<br />Enterthe UNDERLYING CAUSE
<br />(dls.... Or injury th.t Initl.ted (e)
<br />the ev.nts r.sulllng In death)
<br />lAST
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF;
<br />
<br />I ""APPROXIMATE INTERVAL
<br />I i- 8-0z..
<br />
<br />I onset to death
<br />I
<br />I
<br />
<br />_..------1...-. ,,___ _'_
<br />I onsello d..th
<br />I
<br />I
<br />
<br />,-----,- .- ._---,
<br />r onsello death
<br />I
<br />I
<br />--.~
<br />I onset 10 death
<br />I
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition f8$ultlng
<br />In de.th)
<br />
<br />::MEDIAT~ tdrtuvcJ
<br />
<br />-...,. -'-_..~
<br />DUE TO, OR AS A CONSEQU~NCE OF:
<br />
<br />(d)
<br />
<br />PART II. DTHER SIGNIFICANT CONDITIONS-Conditions contribullng 10 Iho dealh bul nol r.sultlng in Ihe underlying c.uee given in PART I.
<br />
<br />----'---,.,~-'''._'_._-'-,_.,--"...._..-...._.._-~.-
<br />
<br />-~._._..~~_..-..
<br />
<br />'<19, WAS MEDICAL EXAMIN~R
<br />
<br />OR CORONER CONTACTED?
<br />
<br />DYES )(NO
<br />'--...'--."-"'---
<br />
<br />,.,,21e, MANNER OF DEATH 21b.IFTRANSPORTATION INJURY 21c, WASAN AUTOPSV PERFORM~D?
<br />
<br />,51 NOI pregnent within pasl yes, '1'h.'illurel 0 Homicide 0 Drlvor/Operator
<br />y~ 0 YES I...IYNO
<br />
<br />o Pre9nsnt alllm. of death 0 Accid.ntO Pending InvesUg.tion U Passenger ____~~__
<br />
<br />
<br />o Nof pregnenl, bul pregn.nt within 42 days of death 0 Suicide 0 Could nol be delermlned 0 Pedeslrl.n 21d, WERE AUTDPSY FINDINGS AVAILABL~ TO
<br />
<br />o Not pregnenl, bUI pregn.nl43 d.ys 10 I ye.r belore de.lh U Other (Sp.cify) COMPLETE CAUS~ OF DEATH?
<br />
<br />
<br />o Unknown If pregnant within Iho p.slye.r __"'_. U YES 0 NO
<br />
<br />---'-"~- -~--- --- ----
<br />22. DATE OF INJURY (Mo , D.y, Yr )_l2: TlM~ OF INJUR~PLACE OF INJURV.At home, f.rm, Slreet, faclory, office bUilding, conslructlon sll., .tc (Speclly)
<br />
<br />
<br />
<br />- 22d INJURYATWORK? -]:2e DESCRIBE HOW INJURY OCCURRED - - -- - -- - - --
<br />o Y~S 0 NO
<br />------------.....----._~--_._--, _.._~
<br />22f. LOCATION OF INJURY. STREET & NUMBER, APT NO. ClTYrrOWN STA~ ZIP CODE
<br />
<br />"1>3., DATE OF DEATH (Mo., D.y, Yr,)
<br />1- 2~-05,___._
<br />
<br />24a, DAT~ SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIM~ OF DEATH
<br />
<br />z,..
<br />,.. <("'
<br />.a(JZ
<br />'llO;~
<br />~.f~~
<br />gffi~~
<br />"z::>
<br />.coo
<br />,20:0
<br />80
<br />
<br />m
<br />
<br />.~..,,_. --.,..--",...-
<br />
<br />24c, PRONOUNCED D~AD (Mo" D.y, vr.) 24d, TlM~ PRONOUNC~D DEAD
<br />m
<br />
<br />24e. On the basis of 8xamlnatlon and/or investigation, in my opinion death OCcurr8d at
<br />Ih. time, dale and pl.ce and due to the caus.(s) st.l.d, (Slgnsluro .nd TltI. ) ,.
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />DYES 0 NO
<br />
<br />1/
<br />
<br />8 2005
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