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<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 />DATE OF ISSUANCE
<br />7/7/2020
<br />LINCOLN NEBRASKA
<br />0200612
<br />;VI 1....1i4tuti.#4 a 111,4>
<br />SARAH BOHNENKAMP f
<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 />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />William Jennings Landis
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Lincoln, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508-54-7796
<br />5a, AGE - Last Birthday
<br />(Yrs.)
<br />76
<br />8b. FACILITY -NAME Of not Institution, glve street and number)
<br />CHI Health St. Francis
<br />8c. CITY OR TOWN ODEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL agi Inpatient
<br />o ER/Outpatient
<br />O DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />MNYrike
<br />AbikilveltittISINtim
<br />20 08068
<br />3. DATE OF DEATH (Mo., Dy,Yr.)
<br />June 17,2020
<br />6. DATE OF BIRTH (Mo., Day; Yr.)
<br />April 27, 1944
<br />OTHER El Nursing Home/LTC
<br />El Decedent's Home
<br />El Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Hospice Facility
<br />9d. STREET AND NUMBER
<br />5301 W. Capital Ave.
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE crnrtimm
<br />DYES> NO
<br />10a. MARITAL STATUS AT TIME OF DEATH Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />'Mb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Margaret A Condon
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Frank Eschlerhan Landis
<br />1 12, MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Ruth Mary Jennings
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) NO
<br />14a. INFORMANT -NAME
<br />Margaret A Landis
<br />14b. RELATIONS IP TO DECEDENT
<br />Wfe
<br />15. METHOD OF DISPOSITION
<br />0 Burial D Donation
<br />kJ Cremation 0 Entombment
<br />O Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />June 18.2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY! TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />It. FART I. Enter:the chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<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:
<br />a) Cardiac Arrest
<br />IMMEDIATE CAUSE (Final
<br />cheeses or condition mauking
<br />In death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)Acute Hypoxic Respiratory Failure
<br />any, Wading to the cause listed
<br />online a.
<br />EritailhdUNDOROMOCCLLISE
<br />idlasaseor Injury that lflhli5ted
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)Acute Respiratory Distress Syndrome
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />onset to death
<br />Unknown
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />ection 30-2413, demands for notice
<br />a.
<br />18. PARTS. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />SNOOK Acute Kidney Injury, Anoxic Brain Encephalopathy, Coronary Artery Disease
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />IZI YES 0 NO
<br />20. IF FEMALE:
<br />[3 Not Pregnant within hest year
<br />ID Pogrom et ono of death
<br />D Net pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />Accident Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Other/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />DYES NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />228.:pATEOPINAM (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OFINJURY-At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />DYES 0 NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221, LO TION OF INJURY STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />HI
<br />00
<br />•
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 17, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />June 18.2020
<br />23e. TIME OF DEATH
<br />06:39 PM
<br />Pd. To the beat of my knowledge, death occurred at the time, date and place
<br />*no dintiOdia Cause(s) stated. (Signature and lltle)
<br />Madhavi Cherukula, MD
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />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 cause(s) stated. (Signature end TItle)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES 1:3 PROBABLY El UNKNOWN
<br />26a. HAS ORGAN OR SSUE DONATION BEEN CONSIDERED?
<br />DYES El NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a is NO DYES
<br />t3 NO
<br />22. NAME, TITLEAND ADDRESS OF CERTIFIER (Type or Print
<br />Madhavi Cherukula, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />I
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 22, 2020
<br />
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