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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 />10/22/2020
<br />LINCOLN, NEBRASKA
<br />20200924
<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 />2013928
<br />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.
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Ronald Harry Palu
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH
<br />October 17,
<br />(Mo„ Day, Yr.)
<br />2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Loup City, Nebraska
<br />(Yrs.)
<br />72
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />March 15, 1948,
<br />7.8OCtAt- SECURITY NUMBER
<br />507-66-1595
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility
<br />eb FACILITY -NAME (if not Institution, give street and number)
<br />CHI Health St. Francis
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)8d.
<br />Grand Island 68803
<br />COUNTY OF DEATH
<br />I Hall
<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 />4157 West Capital Avenue
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE art LIMITS
<br />® YES Q NO
<br />105, MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Janis Marie Shotkoski
<br />11. FATHER'SNAME (First, Middle, Last, Suffix)
<br />Harry Walter Palu
<br />12. MOTHERS -NAME (First, Middle, Malden Surname)s
<br />Madeline Dorothy Kuszak
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) Yes 05/29/1968-05/22/1970
<br />14a. INFORMANT -NAME
<br />Janis Marie Palu
<br />14b. RELATIONSHIP
<br />Spouse
<br />TO DECEDENT
<br />15. METHOD OF DISPOSITION
<br />Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16e. DATE (Mo.,
<br />October
<br />Day, Yr.)
<br />19, 2020
<br />lia Cremation 0 Entombment
<br />0 Removal ❑ Other (Specify)
<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 />Peters Funeral Home, 302 Second Street, PO Box 181, St. Paul, Nebraska
<br />17b. Zip Code
<br />68873
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events- -disuses, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<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 />IMMEDIATE CAUSE(Fina! ;. a/ Respiratory Failure
<br />disease or condition resulting.`
<br />onset to death
<br />Days
<br />MONO) DUE TO, OR ASA CONSEQUENCE OF:
<br />Sequentially list conditions, if b) COVID-19
<br />any, leading to the cause listed
<br />on tines.
<br />onset to death
<br />Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C) Chronic Obstructive Pulmonary Disease Exacerbation
<br />(dileaee or injury that initiated
<br />onset to death
<br />Days
<br />the events resulting in death( DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)Congestive Heart Failure Exacerbation
<br />onset to death
<br />Days
<br />18. PART EI.OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE:
<br />Q Not pregnant within past year
<br />Q Pregnant at ante or death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Dnver/Operat or
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />❑: Nat 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 />Suicide❑ Could not be determined
<br />0 Pedestrian
<br />0 Other (specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH'?
<br />0 YES 0 NO
<br />22e. DATE QF /NARY IMO., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (SpeC#y)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />B1
<br />23a. DATE OF DEATH (Mo., Day, Yr.)_
<br />October 17, 2020
<br />Bgi
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />el> -23b.
<br />I
<br />DATE SIGNED (Mo., Day, Yr.)
<br />October 19. 2020
<br />23c. TIME OF DEATH
<br />06:10 AM
<br />8124c.
<br />La `
<br />€
<br />PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />...,
<br />e !4 Q
<br />':Q.
<br />~ I
<br />23d. To the best of my knowledge, death occurred at the time, dote and place
<br />and due to the -causes( stated. (Signature and Title(
<br />Michael A. Donner, MD
<br />La
<br />" W z
<br />2 z 8
<br />~ ff S
<br />24e. On the basis of examination and/or investigation, In my opinion death occumM at
<br />the time, date and place and due to the causes( stated. (Signature and Title),
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES ❑ NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26aa Is NO Q YES 0 NQ'.
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Michael A. Donner, MD, 729 North Custer Avenue,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />��� B4
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />October 19, 2020 •'
<br />
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