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Val44laF 13 t slid............... .661111 t$$ \NNIAii'Jrfwe,,a aao)M;;tkillQ%kGc.Itr a% �M1II 4rt1gtr4,tsLxex; at4.40/T'(looktaz 4..iy3nrsvik x agzttlfiiri(tRN' una> zn5?AvAMsv t 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 DEPOSITORY2021031 �FOR VITAL RECORDS< DATE OF ISSUANCE rG O 2 0 8 8 2/8/2021 LINCOLN, NEBRASKA 0 E 2 3 w m E 4e )(4.44),) J 47044: SARAH BOHNENKAMP tw 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) Cindy Lou Addison 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Fort Morgan, Colorado 7.; SOCIAL SECURITY NUMBER 245-96-9616 5a. AGE - Last Birthday (Yrs.) 60 8b. FACILITY.F4AME (If not institution, give street and number) UNMC 8c. CITY OR TOWN OF DEATH (Include Zip Code) Omaha 68198 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 5b. UNDER 1 YEAR 2. SEX Female 6c. UNDER 1 DAY MOS. DAYS 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN • Grand Island HOURS MINS. 21 01623 3. DATE OF DEATHIMo,, Day,Yr.) January 5, 2021 6. DATE OF BIRTH'(Mo. Day, Yr.) May 11, .1.960. OTHER 0 Nursing Home/LTC 0 Decedent's Home ❑ Other (Specify) I8d. COUNTY OF DEATH fI Douglas 0 Hospice Facility 9d. STREET AND NUMBER 221 Arapahoe Be. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITYLIMiTS YES 0 NO 10a, MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden nenle Larry Dale Addison 11, FATHER'S -NAME (Firet, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Wayne Calvin Potter Georgia Marie Masters Maiden Surname)<' 13aEVER IN U,S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Larry Dale Addison 14b. RELATIONSHIP TO'DECED Spouse 18. METHOD OF DISPOSITION RI Burial 0 Donation ❑ Cremation 0 Entombment 0 Removal ❑ Other (Specify) 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) January 12, 2021 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Rose Hill Cemetery Palmer STATE Nebraska 17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code.. 68801 CAUSE OF DEATH (See instructions and examples) It. PART 1 Enter the chain of events- diseases, Injuries, or complications4hat 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 on a line. Add additional lines If necessary. IMMEDIATE CAUSE: a) Respiratory Failure 4MEDIATE CAUSE (Final disease or condition resulting in death) Sequentially list conditions, if any, leading to the cause listed on tine C. Enter the UNDERLYING CAUSE (Marmot or Injury that initiated LAST DUE TO, OR AS A CONSEQUENCE OF: b)Septic Shock APPROXIMATE INTERVAL onset to death Days onset to death Days DUE TO, OR AS A CONSEQUENCE OF: c)Aspiration Pneumonia onset to death Weeks DUE TO, OR AS A CONSEQUENCE OF: d)Acute On Chronic Heart Failure 18. PART 11.OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART 1. Sacral Decubitus Pressure Ulcer, Ischemic Cardiomyopathy onset to death Weeks 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED?' ❑ YES NO 20. IF FEMALE: .0Notpregnblll withal past year 0 Pregnant at tl0e of death ❑ :Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death ❑, Unknown 11 pregnant within the past year 21a. MANNER OF DEATH E Natural 0 HomicIde 0 Accident 0 Pending Investigation 0 Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY 0 Driver/Operator ❑: passenger 0 Pedestrian 0 Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES Idj NO 21d. WERE AUTOPSY PINDINGSAVAIL.ABLE 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 slte, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJU 0 RY STREET & NUMBER, APT.NO. CITY/TOWN 23a. DATE OF DEATH (Mo., Day, Yr.) January 5, 2021 23b. DATE SIGNED (Mo., Day, Yr.) February;6, 2021 23e. TIME OF DEATH 11:52 PM 234.70 the bat of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Trek) Steven J. Lisco, MD STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH ZIP CODE 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(*) stated. (Signature and Tale) 25, DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES Q NO 0 PROBABLY E UNKNOWN 2$, NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Steven J.Lisco. MD, 984455 Nebraska Medica Center, Omaha, Nebraska, 68198 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES al NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO 0 YES N 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) February 7, 2021 CD rQ