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to # 8 0 cc w O u. 8 �M. 4 d a. E a a d _ 2 0 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Iva Belle Lowry 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Friend, Nebraska 7. SOCIAL. SECURITY NUMBER 508-12-0651 8b. FACILITY -NAME {If not institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 14576 W. White Cloud Road 10a. MARITALETATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated ® Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME . (First, Middle, Last, Suffix) Joseph Robert Zaiic 13. EVER IN U.S: ARMED FORCES? Give dates of service if Yes. (Yes, No or Utk,) No 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation Cremation ❑ Entombment ❑ Removal <❑ Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska 18 PART l.Entetthe chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation Witt oat showing the etiology. DO NOT ABBREVIATE. Enter only one cause an a Brie. Add additional lines if necessary. IMMEDIATE CAUSE (Final disease or condition resulting in death) Sequentially list conditions. If any, leading to thelcauto gated 00 1 : . ^ . 3 : a Enter the UNDERLYING CAUSE (disease of injury that Inftiated the .events resulting in death) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Entepttalopathy,Aeute On Chronic Kidney Failure, Unknown Primary Cancer, Small Rowel Obstruction tL 20.IF:FEMALE: ❑ Not pregnant within past year U ❑ Pregnant at time of death ❑ No1 pregnant, but pregnant within 42 days of death ❑' Not pregnant; brit pregnaft 43 days to 1 year before death ❑Unknown if pre within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? OYES [ 3 NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 4/30/2018 LINCOLN, NEBRASKA 2 n STANLEY . COOPER 01803751 ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 9b. COUNTY Hall Not Embalmed IMMEDIATE CAUSE: a) Acute Respiratory Failure DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 23a. I3ATE OF DEATH (Mo., Day, Yr.) . w Aprit 25, 2018 & 23b, DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH t 'z Aril 26 2018 04:55 PM a 0 3d. To the best of my knowledge, death occurred at the time, date and place 8 o and due to the cause(s) stated. (Signature and Title) ~ i Madhavi Cherukula, MD 201804657 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 14a. INFORMANT -NAME Mike Lowry 16a. EMBALMER-SIGNATURE 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Robert . White Lowry 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Bessie Ellen Blunt 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN Central Nebraska Cremation Services Gibbon CAUSE OF DEATH (See : instructions and examples) DUE TO, OR AS A CONSEQUENCE OF: b) Bilateral Pulmonary Embolism, Pneumonia CITY /TOWN 95 MOS. DAYS 8a. PLACE OF DEATH HOSPITAL © Inpatient 0 ER/Outpatient ❑ DOA 9c. CITY OR TOWN Cairo 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide 0 Could not be determined 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 25.O10 TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN ❑ YES ® NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Madhavi Cherukula, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803 1 28a. REGISTRAR'S SIGNATURE 21b. W TRANSPORTATION 0 Driver /Operator ❑ Passenger 0 Pedestrian Other (Specify) 16b. LICENSE NO. 2. SEX Female 5c. UNDER 1 DAY HOURS 8d. COUNTY OF DEATH Hall e. APT. NO. l 9f. ZIP CODE 68824 STATE 24a. DATE SIGNED (Mo., Day, Yr.) NJURY 240. PRONOUNCED DEAD (Mo., Day, Yr. MINS OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 24b. TIME OF DEATH 3, DATE OF DEATH (Mo., Day, Yr.) April 25, 2018 ❑ Hospice Facility `9g. INSIDE CITY LIMITS ❑ YES ® NO 14b. RELATIONSHIP: TO DECEDENT Son 16c. DATE (MO., Dal, Yr) April 27, 2018 STATE Nebraska 17b, Zip Code 68801 APPROXIMATEINTERVAL3 onset to d 15 Mins onset to death onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES; E3 NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ I NO 24d. TIME PRONOUNCED DEAD 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) April 30, 2018 26b. WAS CONSENT GRANTED/ Not Applicable if 26a is NO ❑ YES ❑ NO =`