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<br /> STATE OF NEBRASKA
<br />
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AN HUMAN SERVICES, IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA ft Aptvq 'f' 'OF HEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR,,V ~ p Adp 415 t g ~ ~
<br /> c
<br /> DATE OF ISSUANCE t )`Y
<br /> k i
<br /> ;~~r~l!rILE'Yf~..Cdt~PER'
<br /> 05/26/2009 ~ T I,IT, . T TE RE~I57rT~
<br /> EPA )q, H AL rP ANI
<br /> LINCOLN, NEBRASKA NlAl= I
<br /> STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN ~VE6ICESyt >a~ 0901113
<br /> CERTIFICATE OF DEATH ~lW4 '
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2.'8 g Y `A ' • ' S', VATE OF DEATH (Mo., Day, Yr.)
<br /> Jeanne Ellen Saathoff emalea fNa 1%-2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Be. AGE • Last Birthday b. UNDER 1 YEAR tic. UNDER 1 bA 6..DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAYS !!!!![MINS.
<br /> Grand Island, Nebraska 60 May 29, 1948
<br /> 7. SOCIAL SECURITY NUMBER 6a, PLACE OF DEATH
<br /> 506-68-1581 HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility
<br /> §b. FACILITY-NAME (If not Institution, give street and number) ❑ ER/Outpatient ® Decedent's Home
<br /> 305 Villa Mar Dee ❑ DOA ❑ Other (Specify)
<br /> La
<br /> W Be. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br /> o Grand Island 68801 Hall
<br /> 9a. RESIDENCE-STATE 9b. COUNTY Be. CITY OR TOWN
<br /> W Nebraska Hall Grand Island
<br /> LL 9d. STREET AND NUMBER 9e. APT. NO. 9f. ZIP CODE 99. INSIDE CITY LIMITS
<br /> 305 Villa Mar Dee 68801 ® YES ❑ No
<br /> 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br /> ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Dewa ne Saathoff
<br /> 11, FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br /> Walter Cremeen Doris A Douglas
<br /> 13, EVER IN U.S. ARMED FORCES? Give dates of service If Yee. =INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (Yea, No, or Unk.) No Saathoff Husband
<br /> .0 15. METHOD OF DISPOSITION 1Ga. EMBALMERSIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br /> F ❑ Burial ❑ Donation
<br /> Not Embalmed May 19, 2009
<br /> ® Cremation ❑ Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br /> ❑ Removal ❑ Other (Specify)
<br /> Central Nebraska Cremation Services Gibbon Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code
<br /> Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska 68801
<br /> EMSE OF DEATH (See nstruct ons an exam es
<br /> 18. PART I. Enter the chain of eyenta••diseases, injuries. or Complications-that directly caused the death. DO NOT enter terminal events such an urdisc arrest, APPROXIMATE INTERVAL
<br /> respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final a) Alzheimers ; 3 Years
<br /> diaea66 OF cundiUan r.isuions
<br /> in (laaen) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br /> Sequentially list conditions, If b)
<br /> any, leading to the cause listed
<br /> on line a. DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br /> Enter the UNDERLYING CAUSE
<br /> 1018 ase or injury that Initiated
<br /> the events resulting In (loath) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br /> LAST d)
<br /> 18. PART 11. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> lz ❑ YES ® NO
<br /> W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> ® Not pregnant within past year ® Natural ❑ Homicide ❑ Driver/operator ❑ YES ® NO
<br /> v ❑ Pregnant at time of death ❑ Accident ❑ Pending Investigation ❑ Passenger
<br /> ❑ Not pregnant, but pregnant within 42 days of death ❑ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br /> Not pregnant, but pregnant 47 days is 1 year before death ❑ Suicide ❑ Could not be determined Other (Specify) TO COMPLETE CAUSE OF DEATH?
<br /> ❑ ©
<br /> ~a ❑ Unknown if pregnant within the past year ❑ YES ❑ NO
<br /> E 22a, DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc, (Specify)
<br /> s
<br /> 22d, INJURY AT WORK? r e. DESCRIBE HOW INJURY OCCURRED
<br /> FO
<br /> ❑ YES ❑ NO
<br /> 22f. LOCATION OF INJURY - STREET & NUMBER, APT-NO. CITYITOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.) 74e. DATE _91GNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> ' May 19, 2009 £ 5
<br /> u
<br /> 23b. DATE SIGNED (Mo., Day, Yr.) 28c. TIME OF DEATH k r 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> 4 May 19, 2009 12:25 AM
<br /> z
<br /> O 23d. To the beat of my knowledge, death occurred at the time, date and place 24e. On the bads of examination and/or Investigation, In my opinion death occurred at
<br /> and due to the cause(s) stated. (Signature and Title) the time, data and place and due to the cause(s) stated. (Signature and Title)
<br /> ~ Jennifer L. Brown, MD " g s
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN R TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br /> ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO Not Applicable If 26a Is NO ❑ YES ❑ NO
<br /> 27. RXME, TITLE AN I ype or Print)
<br /> Jennifer L, Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr,)
<br /> May 20, 2009
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