|
iom;,41to t3i3t tt1# It 3ldl a9$I l fft?daa�iia hl3k�tua�at4aerl Bay At.tete:
<br />�3��aa��'tsc •� STATE OF NEBRASKA > '•
<br />Oi'ea 1!towuMni `!tttttt)tiSfrltP°°' 'tf oviANya r£rttowswo tea tertttttVare,.: >.
<br />.Y. , � . �.s�t�` �°a, .a..a'c2k"N'i'-�- ;.. .a rx 7C>H-. 3cv v a , L J�rF<s-
<br />WHEN THIS :'COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF. HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DATE OFISSUANCE
<br />1/24/2020
<br />LINCOLN, NEBRASKA
<br />202001173`
<br />" 1. DECEDENTSIAME (First, Middle, Last, Suffix)
<br />Richard Nabity
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr)
<br />January 12, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Ilia AGE - Last Birthday
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />✓ 505-42-2730
<br />G lib. FACILITY -NAME (If not Institution, give street and number)
<br />• CHI Health Bergan Mercy
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />• Omaha 68124
<br />(Yrs.)
<br />83
<br />5b. UNDER 1 YEAR
<br />5e. UNDER 1 DAY
<br />Mt
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ka Inpatient
<br />ERIOutpatlent
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />October 17, 1936
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Douglas
<br />0 Hospice Facility
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />t, 9d. STREET AND NUMBER
<br />$ 2307 West Koenig
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married 0 Never Married
<br />t ❑IMarrted, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />et 11. FATHER'S.NAME (First, Middle, Last, Suffix)
<br />3 Joseph Nabity
<br />9c. CITY OR TOWN
<br />Grand Island
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS`
<br />® YES ❑ NO
<br />10b. NatrtE OF SPOUSE (First, Middle. Last, Suffix) If wife, give maiden name
<br />Annette Margaret Rott
<br />12. MOTHERS -NAME (First, Middle,
<br />Wilhelmina Trubl
<br />Maiden Surname)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />a • (Yes, No, or Unk.) Yes 09/17/1956-08/29/1960
<br />14a. INFORMANT -NAME
<br />Annette Margaret Nabity
<br />8 15. METHOD OF DISPOSITION
<br />at
<br />S 0 Burial 0 Donation
<br />S 0 Cremation 0 Entombment
<br />❑i Removal 0 Other (Specify)
<br />t 17a. FUNERALHOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />u All Faiths Funeral Home. 2929 S. Locust Street, Grand Island. Nebraska
<br />N
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smydra
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />Sb. LICENSE NO.
<br />1454
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16e. DATE (Mo., Day, Yr.}
<br />January 18, 2020
<br />CITY I TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17b. Zip Coda
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />T5. PART T. Smartie chain chain o�nts- diseases, Injuries, or complications -that directly caused the death. DO NOT enter tennbtat events such as cardiac arrest,
<br />aspiratory arrest, et ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one Cause on • lined Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Metastatic Cancer Of Unknown Primary Origin, Acute Renal Faliure
<br />disease or condition musing
<br />In death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />segwnaally slstcandhlans, N >. b)
<br />any. loading to theesus, listed,
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />• Enter the UNDERLYING CAUSE c)
<br />p (disease of injury that initiated.
<br />B the events resulting in death)
<br />B LAST
<br />e,
<br />5 118. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />APPROXIMATE INTERVAL.
<br />onset to death
<br />5 Days
<br />r20. IFFEMALE:
<br />0 Not pregnant within past year
<br />u_
<br />❑ Pregnant at time of death
<br />L
<br />❑: Not pregnant; but pregnant within 42 days of death
<br />Not pregnant, but pregrwnt 43 days to 1 year before death
<br />0 unknewn it gta9nent within the Past yaar
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ NO
<br />V
<br />.2 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />O. YES Q NO
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be deterMined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />Other (Specify)
<br />onset to death
<br />onset to death
<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 />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />t,
<br />a 221. LOCATION OF INJURY STREET 5, HUMBER, APT:,`.(a0.
<br />r
<br />a
<br />S:
<br />'• a
<br />8 aJ
<br />I
<br />`g O
<br />23s. DATE OF DEATH (Mo., Day, Yr.)
<br />January 12, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 16. 2020
<br />CITY.'TOW N
<br />23c. TIME OF DEATH
<br />05:36 PM
<br />23d. To the beat of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Muhammad E. Khan, MD
<br />I25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO ❑ PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or Investigation, In my opinion death occurred at
<br />the tkne, date and place and due to the cause(s) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®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 />Muhammad E, Khan, MD, 7500 Mercy Road, Omaha, Nebraska, 68124,,
<br />2Sa REGISTRARS SIGNATURE
<br />/ �_• �-/. 'Tow � ��..�. ',.
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />January 21, 2020
<br />
|