|
d�I�yk� � tpp���y�,t{,,sgp Y \111 I g ((�11�t�1� )�/(�r�ry ?} 5 Vow 4t1��),if)!iNi 0IiteW.Y.`.eSt.NAr/.{i149ifIs�3fHa4it1,1Z)ii7,i,�ii�5ir(er.Uri �38i)dJ,L�f.1.25R55�I;8im6ew�tQ(i��P,�1(996%%
<br />�� STATE OF NEBRASKA
<br />etrypyµwtt 4., tt*I W4Htlaas,, fi +ytYJPA4da?� �� td691i1xPRiti@S>tv ..Irrg6hnta'\ t�Ih*r,
<br />WHEN 77119 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 />1/19/2021
<br />LINCOLN, NEBRASKASARAH BENAMP
<br />202101443
<br />ASSISTANT STATE REG IS
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />21 00454
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Darrell Robert Balli
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 14, 2021
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Burwell, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />85
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />May 30, 1935
<br />7. SOCIAL SECURITY NUMBER
<br />506-40-1610
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Tiffany Squ..are:Care Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Wood River
<br />OTHER E Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9d. STREET AND NUMBER
<br />1410 Marshall Avenue
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />9g. INSIDE C1TY LIMITS;:
<br />[A YES Q NO
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Lorajane Baskin
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Albert Edwin Bolin Clara Ida Amelia Garska
<br />13. EVER IN U:8. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 09/20/1956-06/30/1958
<br />14a. INFORMANT -NAME
<br />Lorajane Bolli
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑Donation
<br />E Cremation0 Entombment
<br />❑ Removal ' ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />January 15, 2021
<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 />Hitchcock Funeral Home, Inc., 212 Grand Avenue, PO Box 871, Burwell, Nebraska
<br />17b. Zip Code
<br />68823
<br />CAUSE OF DEATH (See instructions and examples)
<br />E
<br />CO
<br />v..
<br />rs
<br />18. 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 fines 1 necessary.
<br />IMMEDIATE CAUSE:
<br />a)Acute Respiratory Failure
<br />IMMEDIATE DAtJIIE (Final
<br />diaease Or =OrWithin '.
<br />in death)
<br />Sequentially list condltlons, if
<br />any, loading to the cause listed
<br />on Ibis a.
<br />Etna} the UNDERLYING CAUSE
<br />(disease or in)urythat Initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Aspiration Pneumonia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) COVID 19 Pneumonia
<br />APPROXIMATE INTERVAL
<br />Ones to death
<br />Imrnedtate
<br />onset to death
<br />Days
<br />onset to death
<br />Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d) Dementia
<br />Years.
<br />18. PART I#, OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Dementia And Chronic Aspiration. Contracted COVID 19 And Transitioned To Hospice And Died
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES .,,E NO
<br />20. IF FEMALE::,
<br />❑ Not pregnene wimtrr past year
<br />❑ Pregnant t11 time of ONO:
<br />0 Not pregrtlint, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑;:,Unknown (1 pregnant within the past year
<br />22a, DATE OF INJURY (Mo., Day, Yr.)
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 could not be determined
<br />22b. TIME OF INJURY
<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 />0 YES ENO
<br />21d. WERE AUTOPSY RNDINGS 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 />❑YES, 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f, LOCATION OF INJURY: STREET & NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 14, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 14, 2021
<br />23c. TIME OF DEATH
<br />12:20 PM
<br />23d. To the bast of my krloWledge, death occurred N the time, date and place
<br />and due to the cause(s) stated. (Signature and Trtie)
<br />Michael A. Donner, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES E NO 0 PROBABLY 0 UNKNOWN
<br />STATE XIP', CODE
<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, data and place and due to the cause(s) stated. (Signature and Title)
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ENO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a is NO ' YES' ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Michael A. Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 15, 2021
<br />1
<br />
|