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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 />5/7/2020
<br />LINCOLN, NEBRASKA
<br />20210348$
<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 />20 05629
<br />d
<br />E
<br />8c, CITY OR TOWN OF DEATH (Include Zip Code)
<br />II Grand Island 68803
<br />d 9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />2407 N. Enoleman Road
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Linda Lee Fisk !>
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Dap Yr:)
<br />April 28, 2020_
<br />4. CITY AND STATE QR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Norfolk, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-66-2213
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY-NAME{tf-ttot Institution, give street and number)
<br />2407 N. Enoleman Road
<br />6
<br />c
<br />0
<br />9b. COUNTY
<br />Hall
<br />72
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />❑ Cca
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yii)
<br />December 10, 1947
<br />OTHER ❑ Nursing Home/LTC
<br />® Decedent's Home
<br />❑ Cithar (^-,pacify)
<br />ed. COUNTY OF DEATH
<br />Hall
<br />0 Hospice Factity
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />90. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />t
<br />0
<br />u
<br />8
<br />0
<br />E
<br />4e
<br />a
<br />d
<br />C
<br />A
<br />E
<br />10a. MARITALSTATUSAT 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 />Kent Errol Fisk
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Robert Renner
<br />13. EVER IN U.S. ARMED IORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) No
<br />15. METHOD OF DISPOSITION
<br />®;Buttal ❑Donation
<br />0 Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />14a. INFORMANT -NAME
<br />Kent Errol Fisk
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Julie Kralik
<br />14b. RELATIONSHIP TODECEDENT
<br />Spouse
<br />16a. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />16b. LICENSE NO.
<br />1071
<br />16e. DATE (Mo., Day, Yr.)
<br />May 4, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Cemetery
<br />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 />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events- diseases, injuries, or compllcations4hat 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 it necessary.
<br />IMMEDIATE CAUSE:
<br />e)Acute On Chronic Rccairstc: f F�ilur�
<br />lMatw%.Af n;:3E trim:
<br />disease or condition resulting
<br />in degth#
<br />Sequentially list conditions, If
<br />any, leading to the cause listed
<br />on knits.
<br />Enter: the UNDERLYING CAUSE
<br />(Must, or 'Moly that initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Multisystem Atrophy - Parkinson's Variant
<br />]7b. ZIpCode,;;
<br />88801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />5 Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />onest le death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />18. PART ti. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART 1.
<br />Hypertension, Episodic Orthostatic Hypotension, Spinal Stenosis Of Lumbar Spine, Urine Retention, Autonomic Dysfunction,
<br />Anxiety, HIO Pulmonary Emboli/deep Vein Thrombosis
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />0. IF FEMALE:
<br />Nth ;Regnant within pastyear
<br />0 Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown H pcegnam within the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />❑ Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES gl NO
<br />21d. WERE AUTOPSY F)NDiNGSAYAILA
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22s. DATE OF INJURY (Ma 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 />OYES ONO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f, LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN
<br />e.
<br />1
<br />23a. DATE 3F' DEATH (Mo., Day, Yr.)
<br />April 28, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />April 30, 2020
<br />23c. TIME OF DEATH
<br />07:35 AM
<br />22d. To the best of my.knowle Age, death occurred at the One, date and place
<br />ante due tache cause(s) stated. (Signature and Title)
<br />Kimberly A. Mickels, MD
<br />STATE ZIP: CODE
<br />24e. DATE SIGNED (Mo.. Day, Yr.) 124b. TIME OF DEATH
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)1 24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, in my opinion deIth oCCar ed 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? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YES El NO ❑ PROBABLY 0 UNKNOWN 0 YES ® NO
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />8e,�,yt7
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO OYES ❑ NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 4, 2020
<br />
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