|
AV
<br />i txltt a - ist9
<br />rrilGe14.�1)7))i+�w1�, d1/tl.t. tiRreN.i �L STATE
<br />VO7�Figp,�PlN1ry, �iIiiEYABlnFiR-.-.Ah, lgS�g Kgge
<br />:; Met A'F' Ml,Op/1}1
<br />4:111/
<br />} xs26t6WtiAi(fOaASD fatyiriri�i4`hR2 - , .sv/IIItilsfftlatx irrrgm,tx tYh1 Zl
<br />WHEN THIS r` 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 />5/12/2020
<br />LINCOLN, NEBRASKA
<br />20200681i
<br />11 I44
<br />SARAH BOHNENKAMP
<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 />20 05566
<br />1. DECE:ENTS-NAME (First, Middle, Last, Suffix)
<br />Sallie Sue Alberts
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr:)
<br />April 23, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Fort Collins, Colorado
<br />5a. AGE - Last Birthday,
<br />(Yrs.)
<br />71
<br />Sb. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (No.. Dsy, Yr)
<br />April23, 1949
<br />7. SOCIAL SECURITY NUMBER
<br />508-64-1260
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHL Health Nebraska Heart
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />0 Hospice Facility
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Lincoln 68526
<br />I8d. COUNTY OF DEATH
<br />Lancaster
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />2540 N North Road
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY UNITS;
<br />jj YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) H wife, give maiden name
<br />William Conrad Alberts
<br />11. FATHER'S -NAME (Fiat, Middle, Last, Suffix)
<br />Eimer Elmshaeuser
<br />12. MOTHER'S -NAME (First,
<br />Florence Bucher
<br />Middle, Malden Surname)
<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 />William Conrad Alberts
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑';Burial ; ❑ Donation
<br />® Cremation ❑ Entombment
<br />❑'Removal < 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />April 27, 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 MA LING ADDRESS (Street, City or Town, State)
<br />Alt Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />13. PART 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 one line. Add additional tines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Flnal a) Cardiopulmonary Arrest
<br />disease or condition resulting
<br />In death
<br />Sequentially list conditions, If
<br />any, leading to the. cause listed
<br />on rias a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury that initiated
<br />the events resulting in death)
<br />LAST
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />HourS
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Cardiogenic Shock
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Coronary Artery Disease
<br />onset to death
<br />Hours
<br />onset *death
<br />Months
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />Respiratory Failure, Recent Valve And Bypass Surgery, Renal Disease.
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE:
<br />® Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not 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 />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />❑ Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<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 />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc (Specify)
<br />22d. INJURY AT WORK?
<br />DYES ❑ NO,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22r. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 23, 2020
<br />CITY/TOWN"
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />April 27.2020
<br />23c. TIME OF DEATH
<br />05:43 AM
<br />tad. To the beet of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Omar Nass, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO ❑ PROBABLY I UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP CODE
<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 odslaredat
<br />the time, date and place and due to the causes) stated. (Signature and ThIe)
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />®YES ❑NO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 26e is NO ❑ YES
<br />Mao
<br />27. NAME, TTLEAND ADDRESS OF CERTIFIER (Type or Print
<br />Omar Nass, MD, 7440 S 91st St, Lincoln, Nebraska, 68526
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 30, 2020
<br />
|