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<br />WHEN THIS '`COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE
<br />ON FILE WITH
<br />RECORDS OFFICE,
<br />DATE OF ISSUANCE
<br />11/12/2019
<br />LINCOLN, NEBRASKA
<br />DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />WHICH IS THE LEGAL DEPOSITORY FOR VITAL. RECORDS
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />201907291
<br />1914081
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Donna Dorine Rawlings
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />October 29, 2019
<br />CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Westerville, Nebraska
<br />$ 7. SOCIAL SECURITY NUMBER
<br />s; 506-50-1678
<br />5a. AGE Last Bfthday
<br />(Yrs.)
<br />81
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />M
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo, Day, Yr.).
<br />February 17, 1938
<br />t 8b. FACILITY -NAME ()f not institution; give street and number)
<br />4*
<br />CHI Health St. Francis
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />0 ER/Outpetient
<br />5
<br />❑ DOA
<br />OTHER ❑ Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ ("Thar (Specify)
<br />0 Hospice Facility
<br />m
<br />« 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />4 Grand Island 68803
<br />I 9a, RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9b. COUNTY
<br />Hall
<br />9a CITY OR TOWN
<br />Grand) Island
<br />2028 N. Howard Ave.,
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />❑ Married, but separated. ® Widowed 0 Divorced ❑ Unknown
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10b, NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Robert Rawlings
<br />E 11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Jesse Dimmitt
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yea, No, or Urlk.) NO
<br />3
<br />4*
<br />5
<br />tai
<br />112. MOTHER'S -NAME (First, Middle,
<br />Ruth Fox
<br />Maiden Surname)
<br />15. METHOD OP DISPOSITION
<br />® Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other{Specify)
<br />14a. INFORMANT -NAME
<br />Debra Martinez
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />156. LICENSE NO.
<br />1454
<br />16c. DATE (Mo., Day Yr.)
<br />November 5, 2019
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />CITY / TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />o' All Faiths Funeral Home, 2929 S. Locust Street. Grand Island. Nebraska
<br />m
<br />ar
<br />«
<br />P
<br />C,
<br />4*
<br />17b.2.1p Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18: PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death, DO NOT enter terminad *vents such as cardiac arrest,
<br />respiratory street 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:
<br />IMMEDIATE CAUSE (Final a) Sepsis
<br />disease or condition resulting
<br />death)
<br />Sequa ltlally Est PmEEt00d,11
<br />any, )coding to 4h• mitre 110 4
<br />on line 11.
<br />Ener the UNDERLYING CAUSE
<br />(*see** or Injury that initiated::
<br />the events resulting in death)
<br />LAST:'.
<br />APPROX)MATEINT ERVAL
<br />onset to death
<br />Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Aspiration Pneumonia
<br />onset to death::
<br />Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Pancreatic Cancer
<br />onset to death
<br />2 Months
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)Smoking
<br />onset to dead)"
<br />60 Years
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />Chronic Obstructive Pulmonary Disease
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ No
<br />O'
<br />M
<br />0. IF FEMALE:
<br />0 Not pregnant within past year
<br />❑ Pregnant at time of death
<br />07 Not pregnant, but tannin* within 42 days of death
<br />L_1 Not pregnant,. but pregnant 43 days to 1 year before death
<br />0 Unknown N pregnant Within the past year
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide
<br />0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Dep, Yr.) 122E. TJ.`.C•''
<br />22d. INJURY AT: WORK?
<br />0YES 0 N
<br />21c. rL..CE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />y 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />I23a. DATE OF DEATH (Mo., Day, Yr.)
<br />Z. 13 October 29,'2019
<br />Y 23b. DATE SIGNED (Mo., Day, Yr.)
<br />CITY/TOWN STATE
<br />23c. TIME OF DEATH
<br />2
<br />08:45 PM
<br />u ` O 3d. ToTothe beststof my knowidge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Title)
<br />2:acharY W. Meyer, MD
<br />S
<br />w°
<br />25. DID TO)RACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES 0 NO 0 PROBABLY 0 UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />ZIP CODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.i 24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or Investigation, In my opinion death occurred at
<br />the time, date and place and due to the camels) stated. (Signature and Tiffs)
<br />26a. HAS ORGAN OR TISSUE r • ATioN BEEN CONSIDERED?
<br />❑ YES 7 NO
<br />26b. WAS CONSENT GRANTED/
<br />Not Applicable If 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Zachary W. Meyer, MD, 2116 W Faidley #400, Box 9802, Grand Island, ►; raska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Ma, Day, Yr.)
<br />November 6, 2019
<br />
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