|
U ti.�tSY�SFt11rt6159Rk2fig6SdtltZi�),I�91h'�ri3%IF
<br />a��8d$I��i�ti��ll�11¢3Ju.wa�at�i,�,i,V,V,4$y0is �
<br />atwuue YYt$ttltiyltititltAv. .,,, /tik rtY//tytnrlftttsi? fYYlttt�ddAt1 ¢tP,Y
<br />�,4yaritst�!/f,
<br />WHEN THIS . COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />5/5/2020
<br />LINCOLN, NEBRASKA
<br />0
<br />d
<br />E
<br />the county where the di
<br />0
<br />202009982
<br />g/
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (first, Middle, Last, Suffix)
<br />Donald Gene Razey
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kearney, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-64-2188
<br />5a. AGE - Last Birthday
<br />(YrL)
<br />69
<br />8b. PACILIW.NAME (If not Institution, give street and number)
<br />520 Midaro'Dr.
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />20 05558
<br />3. DATE OF DEATH .(Mo., Day; Yr.)
<br />April 25, 2020
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />May 23, 1950.
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />Grand Island 68801 Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />520 M(daro Dr,
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />$g. INSIDE CITY LIMITS'
<br />®YES ❑ NO
<br />10a, MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name
<br />Deborah Jean Petersen
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Lloyd Richard Razev Sr
<br />1 12. MOTHER'S -NAME (First,
<br />Eva Fay Collins
<br />Middle, Maiden Sumame)
<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 />Deborah Jean Razey
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DrI^S�POSITION
<br />u
<br />13 BNr*al Donation
<br />❑ Cremation [Entombment
<br />❑Removal ❑Other(Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />16b. LICENSE NO.
<br />1071
<br />18c. DATE (Mo., Day, Yr.)
<br />April 29, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Cemetery Grand Island
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All 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 />IL 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 on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a)Acute Myeloid Leukemia
<br />IMMEDIATE CAUSE (Final
<br />**ease 0r Condition reeuaing,
<br />in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading to the cause listed
<br />rine a
<br />on
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />1 Year...
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />(1105040 Or injury that initiated
<br />onset:
<br />death
<br />Inc events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18 PART II. 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 />Not pregnant *thinnest year
<br />Q Pregnant at time of death
<br />❑ ;Net pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown If pregnant within the past year
<br />21a. MANNER OF DEATH
<br />El Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES II NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY: STREET & NUMBER, APT.NO. CITY/TOWN
<br />0
<br />23a.`DATE 'OF DEATH (Mo., Day, Yr.)
<br />April 25, 2020
<br />23b, DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />April 30, 2020 08:23 PM
<br />23d. To the beet dray knowledge, death occurred at Inc time, date and place
<br />and due tett* cause(*) stated. (Signature and Title)
<br />Ryan Ramaekers, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES E] NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR SSUE DO
<br />DYES bla NO
<br />STATE ZIP;;P0DE
<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(*) stated. (Signature and Title)
<br />ATION BEEN CONSIDERED?
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan Rarnaekers, MD, 2116 W. Faidley Avenue, Grand Island, Nebraska, :8803
<br />28a. REGISTRAR'S SIGNATURE j
<br />4.11
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ; O YES
<br />❑ 0
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 30, 2020
<br />
|