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1ST in rcatif4GixbY`ItdA: 7,3Switdaa +attt"Mtlt V33 +: c .:. 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 10/19/2020 LINCOLN, NEBRASKA 20200843 • C.-/ is t.ff, SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES C 20 13876 Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death, I - 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Larry Robert Badura 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) October 10, 2020 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last Birthday Sb. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Elba, Nebraska (Yrs.) 73 MOS. DAYS HOURS MINS. January14, 1947 7. SOCIAL SECURITY.NUMBER 508-54-3116 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER 0 Nursing Home/LTC ' Q Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 0 ER/Outpatient 0 Decedent's Home 0 DOA ❑ Other (Specify) 8a, CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1722 Doreen Street 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY;LIMITS ® YES Q NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Marded, but separated ❑ Widowed 0 Divorced 0 Unknown 1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Nancy Joan Roy 11, FATHER'S -NAME (FIrst, Middle, Last, Suffix) Donald Badura'< 12. MOTHER'S -NAME (First, Middle, Maiden Surname); Louise Tesmer 13, EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 12/29/1965-12/13/1967 14a. INFORMANT -NAME Nancy Joan Badura 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF Burial DISPOSITION 0Donatan 16a. EMBALMER -SIGNATURE Stacie L Cook 16b. LICENSE NO. 1495 16c. DATE (Mo., Day, Yr.)gi October 16, 2020 0 Cremation Q Removal ©Entombment 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 1713. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) It. PART I. Enter the chain of events- -diseases, injuries, or complicetiora.ltat directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATEcauSEreal ;. a)Traumatic Intracranial Hemorrhage disease or condition resulting onset to death Immediate !, in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) Hepatic Encephalopathy any, leading to. the cause listed on Shea onset to death DUE TO, OR AS A CONSEQUENCE OF: Order t y UNDERLYING OAUSE c) Nonalcoholic Liver Cirrhosis (Malaita or injury that initiated onset to death the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART II, OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I. Post Traumatic Stress Disorder, Severe Protein Calorie Malnutrition, Diabetes, Hypertension, Esophageal Varices 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: 0 Notpregnant within pant year Q Pregnentat time of death 21a. MANNER OF DEATH 0 Natural 0 Homicide ® Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES lia NO Q Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death ❑. Unknown if pregnant within the past year I1 Suicide ❑could not be determined ❑Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES 0 NO 22a. DATE OFINJURY (Nto., Day, Yr.) October 3, 2020 22b. TIME OF INJURY Unknown 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, eta. (Specify) Home 22d. INJURY AT WORK? El YES ®No 22e. DESCRIBE HOW INJURY OCCURRED Accidental fall as patient was trying to get inside his house from garage 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 1722 Doreen Street. Grand island Nebraska 68803 To becompleted by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) October 10, 2020 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) October 16, 2020 23c. TIME OF DEATH 12:35 AM 244. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. To the bast et my knowledge, death occurred at the time, date and place Med due Se the causes) stated. (Signature and Title) Manoi Suryanarayanan, MD 24e. On the basis of examination and/or investigation, In my opinion death OCcutred at the time, date and place and due to the auas(s) stated. (Signature And Tide);. 26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES ,® NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 50 NO 28b. WAS CONSENT GRANTED,? Not Applicable If 26a Is NO Q YES 0 NO 21 NAME, -OLE AND ADDRESS OF CERTIFIER (Type or Print Manoj Suryanarayanan, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURELi46 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 16, 2020 I) a. cJ,