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riko $yldea u. rmr NSA 3>nth„441T9.'tliFrw.au iSI A%E $e) #,(scatula( F ;r;4Z) %1sauAMINO$3teeetaietliAN :SwF.c: hw 'T:1ltttrdmq?!X 6 x.14YAY@Ni 3 rt ('11"14= 3 .!.:..,_. _.v�Y.3E.lty __..... g r..�:1ikS. ..;..:. itc a3, ,14t u,4e,fir :..moo.. 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 11/2/2020 LINCOLN, NEBRASKASARAH BOHNENKAMP s 6 202009531 ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1, DECEDENTS -NAME (First, Middle, Last, Suffix) Allen Eugene Gingrich 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 62 5b. UNDER 1 YEAR 2. SEX Male Sc. UNDER 1 DAY MOS. DAYS HOURS MINS. 1810437 3. DATE OF DEATH (Mo,, Day, Yr.) August 11, 2018: 6. DATE OF BIRTH (Mo., Day, Yr.) 7. SOCIAL. SECURITY NUMBER 506.84-2211 8b. FACILITY•NAME'(It not Institution, give street and number) CHI Health Nebraska Heart Sc. CITY OR TOWN OF DEATH (Include Zip Code) Lincoln 68526 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island June 26, 1956 OTHER 0 Nursing Home/LTC 0 Decedent's Home ❑ Other (Specify) I8d. COUNTY OF DEATH Lancaster Hospice F Ility 9d STREET AND NUMBER 524 West Avenue Be. APT. NO. 9f. ZIP CODE 68803 �. INSIDE CITY LIMITS ® YES 0 NO los. MARITAL STATUS' AT TIME OF DEATH 0 Married ❑ Never Married 0 Married, but separated 0 Widowed ® Divorced 0 Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Wilbur Eugene Gingrich Bertha Grace Weakly 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Mariah Talare Gingrich 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ❑Burial ❑Donation I] Cremation Q Entombment ❑ Removal Q Other (Specify) 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) August 13, 2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY i TOWN Central Nebraska Cremation Services Gibbon STATE Nebraska 17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 688011 CAUSE OF DEATH (See instructionsandexamples) 13. PART I. Enter the chain of events- -diseases, injuries, or complicatlons4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines it necessary. IMMEDIATE CAUSE: a) Card ioRespiratory Distress IMMEDIATE CAUSE (Final disease or condition resulting in death) Sequentially list conditions, If any, leading to the cause listed online a. Enter the UNDERLYING GAUGE (Mamma or Injury that initiated the events resulting in death) LAST APPROXIMATE INTERVAL onset to death 5 Days DUE TO, OR AS A CONSEQUENCE OF: b)Heart Failure onset to death 5 Days DUE TO, OR AS A CONSEQUENCE OF: c) onset to death DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 18. PART R. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I. VEntricular Tachycardia, Hypoxia 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: ❑.' Not Pregnant wINdn past, year Pregnant et time of death ❑ Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide 0 Accident ❑ Pending Investigation 0 Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator 0 Passenger 0 Pedestrian 0 Other (Specify) 21e. WAS AN AUTOPSYPERFORMED? ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑NO... 22a DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc, (Specify) 22d. INJURY AT WORK? a, el A c o 4° 511 ,S " o V e 0 a. El YES NO 22e. DESCRIBE HOW INJURY OCCURRED 22f, LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) August 11, 2018 23b. DATE SIGNED (Mo., Day, Yr.) August 13, 2018 23c. TIME OF DEATH 05:44 PM 3d. To the least Of My knowledge, death occurred at the time, date and place end that to the cause(s) stated. (Signature and Title) Anuradha Tunuguntla, MD 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title)< 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES ®NO 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ;❑ NO 0 PROBABLY ® UNKNOWN 27. NAME, rill ANb A IORESS OF CERTIFIER (Type or Print Anuradha Tunuguntla, MD, 3219 Central Avenue, Ste 201, Kearney, Nebraska, 68847 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ` Q YES ❑ N' 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I August 16, 2018