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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO SEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATJSMS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />OCT 312007 200709665 As^ IS wQ ��TER� EA
<br />LINCOLN, NEBRASKA HEALM AI(ID uMaN SE�AVJI1r S �-
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FiK A&G &U
<br />CI= RTIFICATE OF DEATH
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />2, r
<br />"•
<br />13.D, r7Ff3,FeAT ,'Me., Day, Yr.)
<br />X007
<br />Sondra Joy Niemoth
<br />Fe1r, l
<br />2 ,
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE -Last Birthday
<br />5b, UNDER 1 YEAR
<br />Sc. �JN?E..I Q �,
<br />16.Q)iR7e MTH.[Mo.. Day. Yr.)
<br />(Yrs.)
<br />MOS.
<br />DAYS
<br />HOURS
<br />Grand Island, Nebraska
<br />73
<br />J,
<br />r ,,
<br />: . oviprribet -'20, 10
<br />7. SOCIAL SECURITY NUMBER
<br />Ba. PLACE OF DEATH
<br />507 -34 -5970
<br />C1 iIng,
<br />j Q§PITAL: ❑ Inpatient g�9: NusingHame /LTC L�HosplceFacility
<br />❑ ER /Outpatient Q Decedent's Home
<br />8b. FACILITY -NAME (it not Institution, give street and number)
<br />Saint Francis Medical Center Hospice
<br />- LI aaA Q o91er(speciry)_ _
<br />So. CITY OR TOWN OF DEATH (Include Zip Code)
<br />8d. COUNTY OF DEATH
<br />Grand Island 68803
<br />Hall
<br />9a. RESIDENCE-STATE 9b.000NTY 9c. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />9d, STREET AND NUMBER 9e. APT, NO 9f. ZIP CODE 9g.INSIDE CITY LIMITS
<br />2320 W 5th St 68803 Lid YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DcATH y(J Married C Never Married 'tub. NAME OF SPOUSE (Firsl, Mi idle, Last, Suhix) If w'fe, give maiden name.
<br />❑ Married, but sepaiateo CI Widowed ❑ Divorced ❑ Unknown
<br />Donald Niemoth
<br />11. FATHER'S•NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Maiden Surname)
<br />Vanair Patrick Wagner Alma Niefelt
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service ifyes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />(Yes, no. at unk.) No Donald Niemoth Husband
<br />15. METHOD OF DISPOSITION 16a. EMBAL GNATURE 16b- LICENSE N0. t6c. DATE (Mo., Day, Yr. )
<br />LA Burial U Donation /' ��9 October 25, 2007
<br />LJ Cremation 1J Entombment 16d. CEMETERY, CREMAT OR OTHER LOCAT CITY / TOWN STATE
<br />❑Removal ❑ Other (Specify)
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Stale) 17b. Zip Code
<br />Livingston - Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 68803
<br />CAUSE OF DEATH (See instructions and examples)
<br />I. Ent er the chain of event€- •diseases, injuries, or complications -•that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />r18PA.F,IT
<br />atory arrest, orventrlcular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enteronly one cause on a line. Add additional lines if necessary. I
<br />IMMEDIATE CAUSE: 1 onset to death
<br />IMMEDIATE CAUSE (Final ` 'Q
<br />disease otcorldilionresulling DUE TD, OR AS A CONSEQUENCE 05: t onsetlodealh
<br />d
<br />in death)
<br />I
<br />�)
<br />Sequentially list conditions, If l
<br />any, leading to the cause listed DUE T0, OR AS A CONSEQUENCE OF! I onsel to death
<br />on line a. I
<br />Enter the UNDERLYING CAUSE I
<br />(disease or Injury that Initiated (c)
<br />the events resulting In death) DUE TO. OR AS A CONSEQUENCE OF; I onset to death
<br />LAST I
<br />(d)
<br />®. PART IL OTHER SIGNIFICANT CONOITIONS•Condilions contributing to the death but not resulting In the underlying cause given In PART I, ® WAS MEDICAL EXAMINER
<br />r ^ \ OR CORONER CONTACTEDI
<br />❑ YES 1"NO
<br />®IFFEMALE: Ca. MANNER OFDEATH 21b.IF TRANSPORTATION INJURY 21c.WASANAUTOPSYPERFORMED?
<br />uJ Matural ❑ Homicide ❑ Doverloperator
<br />❑ YES O
<br />A(olpregnanlwithinpastyear
<br />©Passenger
<br />U Pregnant at time of death U Accident❑ Pending Investigation
<br />❑Pedestrian 21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />i U Not pregnant, but pregnant within 42 days of death ❑ Sulclde Q Could not be determined
<br />l0 Other (Specify) COMPLETE CAUSE OF DEATH?
<br />Q Not piegnanl, but pregnant 43 days toI year before deadT
<br />i -
<br />Q Unknown ifpregnantwithinthepaslyear ❑YES ❑ND
<br />22a. DATE OF INJURY (MO., Day, Yr.) 221b . TIME OF INJURY 22c. PLACE OF INJURY•Alhome, farm, street, factory, office building, construction site, etc.(Specily)
<br />m
<br />t
<br />22d.INJURYA`WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />❑ YES ❑ NO
<br />221. LOCATION OF INJURY • STREET & NUMBER, APT. NO. CITYITOWN STATE ZIP CODE
<br />TH(Mo.,Day,Yr.) 7- 24a.DATESIGNED(Mo.,Day,Yr.) 24b.TIMEOFDEATH
<br />a" '\ nc4z 171
<br />D (Mo., Day.Yr. TIME OF DEATH _ 24c. PRONOUNCED DEAD (MO., Day, Yr.) 24d. TIME PRONOUNCEDDEAD
<br />a m
<br />m �o
<br />F_1
<br />f my knowledge, deals occurred al the Ilme, dale and place z ? 24e. On the basis of examination andlorinvesligallon, in my opinion death occurred al
<br />e causels (Sign N�\L and Title) 0 0 p the time, date and place and due to the cause(s) slated. (5ignalule and Title) V
<br />CC
<br />�� 1200
<br />O o
<br />�
<br />( DID TOBACCO USE CONTRIBUTE TO THE DEATH? QAa. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED 263 WAS CONSENT GRANTED)
<br />Ll Y BABLY U UNKNOWN ❑YES L�794Q Not Applicable if 26a is NO C1 YES �NO
<br />- RESSOFCERTIFIER PHY DRONER 'SPHYSICIANORCOUNTYATTORNEY) (lypeorPnnl)
<br />Dr. John Cannella, M.D. P sician, 729 N Custer Grand Island NE 688
<br />26b. DATE FILED BY REGISTRAR (Mo., Day, Yr,)
<br />28a. REGISTRAR'S SIGNATURE
<br />j OCT 2 9 2007
<br />Akx4j, �,
<br />
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