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waaatt r rr 11111ITHI i!¢ AltiM31f' g rd`.;4$691 y4ririlh'aNa r<tt5!lllTfff!!!!ffa ; +' xrrr9AtpaAvt r ;< 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 5/27/2020 LINCOLN, NEBRASKA 202103G1i SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 20 06670 1. DECEDENV_S-NAME .(Firer Middle, Last, Suffix) Ikukfl Curtis 2. SEX Female 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Japan 4. 7. SOCIAL SECURITY NUMBER 505.58»0184 c 8b. FACILITY-NAME(N not Institution, give street and number) E M: Ts 73 S 0 t 1 CHI Health t. .Francis 8c. <CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 6$803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 2021 West 10th Street 9b. COUNTY Hall 5a. AGE - Last Birthday (Yrs.) 90. 5b. UNDER 1 YEAR 5c. UNDER 1 DAY MOS. DAYS 8a. PLACE OF DEATH HOSPITAL a, Inpatient ❑ ER/Outpatient ❑ DOA lea. MARITAL. STATUS AT TIME OF DEATH ® Married 0 Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown 9c. CITY OR TOWN Grand Island HOURS MINS. 3. DATE OF DEATH,(Mo> Days May 20, 2020 6. DATE OF BIRTH (Mo., Day, Yr.) April 3, 1930 OTHER 0 Nursing Home/LTC ❑ Hospice Facility ❑ Decedent's Home ❑ Other (Specify) _ I8d. COUNTY OF DEATH Hall 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS t0b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Anton Loyd Curtis 11. FATHER'S -NAME (First, Middle, Last, Suffix) Kano Yasuoka 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No I12. MOTHER'S -NAME (First, Middle, Yoshiko " Takemoto 14a. INFORMANT -NAME Anton Loyd Curtis Maiden Sumame) 15. METHOD OF DIS❑POSITION Burial Donation Cremation 0 Entombment 0 Removal' 0 Other (Specify) 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr;) May 21 2020 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE Nebraska lla. FUNERAL HOME ME AND MAILING ADDRESS (Street, City or Town, State) Higgins Funeral Home, 321 0 Street, PO Box 323, Loup City, Nebraska CAUSE OF DEATH (See instruptions and examples) 17b.:Zlp Code 68858 18. PART 1. Enter the chain of events- .dbsases, 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 M necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (final a) Subarachnoid Hemorrhage, Stroke etsease car condition raeuhing lit death) - DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) any, leading to the cause listed OR line a DUE TO, OR AS A CONSEQUENCE OF: Enter the UNIIERLYING CAUSE c) (dis8ase or injury Mit imitated the events resulting in death) LAST APPROXIMATE INTERVAL onsetto death 12 Hours • onset to death onsetto death:` .; DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 18. PART fl. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting i in the underlying cause given in PART I. Hypertension 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO ,20. IF FEMALE) 11Not pregnant witidn peat::ysar ❑. Pregeant attirlu of death- Q. Not progn0M, bot pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death O Unknown if:pregnant within the past year 22a. DATE OF INJURY (Ms., Day, Yr.) 22d. INJURY AT WORK? 0 YES .<❑ NO .. 21a. MANNER OF DEATH ® Natural 9 Homicide 0 Accident O Pending Investigation 0 Suicide 0 Could not be determined 22b. TIME OF INJURY 21b. IF TRANSPORTATION INJURY ❑ Diver/Operator 0 passenger 0 Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES II NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES ❑ 22e. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etr4.4Spectfy) 22e. DESCRIBE HOW INJURY OCCURRED 22t. LOCATION'OF iNJURV STREET & NUMBER, APT.NO. CITY/TOWN 23a. DATE OF DEATH (Mo., Day, Yr.) May 20, 2020 23b. DATE SIGNED (Mo., Day, Yr.) May 21, 2020 23c. TIME OF DEATH 03:30 AM 23d. Ta the best Of my knowledge, death occurred at the time, date and place end due td theeause(s) stated. (Signature and Title) Jane A. McDonald, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? :0 YES NO ❑ PROBABLY 0 UNKNOWN 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, M my opinion death accursed at the lime, data and place and due to the cause(e) stated. (Signatursand.Title)` 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES I NO 26b. WAS CONSENT GRANTED? ; Not Applicable if 265 Is NO ❑ YES: 27. NAME, Trite AND ADDRESS OF CERTIFIER (Type or Print Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803 28e. REGISTRAR'S SIGNATURE 6i(--44-111 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) May 26, 2020 .. 1 W< F CO