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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 />bac f
<br />DATE OFISSUANCE
<br />4/16/2021x r'a.a sl`.f,►
<br />LINCOLN, NEBRASKA 202104338 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 2104781
<br />1. DECEDENT'S -NAME IFIrst, Middle, Last, Suffix)
<br />2. SEX
<br />3. DATE OF DEATH (Mo, Day, Yr.)
<br />James Paul Thomas
<br />Male
<br />April 8, 2021
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Sa. AGE -Last Birthday
<br />5b.UNDER1YEAR
<br />5c. UNDER 1 DAY
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />DAYS
<br />HOURS
<br />MINS.
<br />(Yrs.)MOS.
<br />Aberdeen, South Dakota
<br />60
<br />December 20, 1960
<br />L SOCIAL SECURITY NUMBER
<br />8a. PLACE OF DEATH
<br />qi
<br />504.84-2504
<br />HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility
<br />8b'FACILITYNAMEINnot Institution, give street and number)
<br />.6
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />N
<br />CHI Health St. Francis
<br />❑ DOA ❑ Other (Specify)
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />fid. COUNTY OF DEATH
<br />A
<br />Grand Island 68803
<br />Hall
<br />32
<br />Be. RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY OR TOWN
<br />Nebraska
<br />Hall
<br />Grand Island
<br />9d, STREET AND NUMBER
<br />e. APT. NO.
<br />9f. ZIP CODE
<br />9g. tNS1DE CITY LIMITS
<br />3102 E Seedling Mile Road
<br />68801
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />IS
<br />❑ Married, but separated []Widowed ❑ Divorced []Unknown
<br />$ally Sue Peterson
<br />..
<br />11. FATHER'S.NAME (First, Middle, Last, Suffix)
<br />12. MOTHER'S -NAME (Fire% Middle, Maiden Surname),
<br />Anton Thomas
<br />Mary Louise Heinz
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />14a. INFORMANT -NAME
<br />14b. RELATIONSHIP TO DECEDENT
<br />o'
<br />(Yes, No, or Unk.) Yes 01/02/1980-01/02/1983
<br />Sally Sue Thomas
<br />Spouse
<br />m
<br />15. METHOD OF DISPOSITION
<br />18a. EMBALMER -SIGNATURE
<br />18b. LICENSE NO.
<br />18c. DATE (Mo., Day, Yr.) ,
<br />] Burial ❑ Oortation
<br />Q Cremation ❑ Enttutibment
<br />Not Embalmed
<br />April 10 2021
<br />18d CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Removal [].Other (Specify)
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />17b. ZIP Code
<br />Alt Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />68801!
<br />E
<br />CAUSE OF DEATH (See instructions and exam les
<br />-�
<br />1S. PART 1. Enter the chain of events- diseases, Injuries, or complications tat directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />3
<br />respiratory arrest, or vermicular fibrillation without shoving the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines H necessary.
<br />IMMEDIATE CAUSE: onset to death
<br />+a"
<br />IMMEDIATE CAUSE( Fina a)Acute Hypoxic Respiratory Failure
<br />IV
<br />disease dr ctmdltiort reaultkrg
<br />In death)
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />dSequentially
<br />list conditions, if b)Acute Respiratory Distress Syndrome
<br />any,. leading to the cause listed
<br />on ilii# m
<br />DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />Smerthe UNDHRLYINGGAISE C)COVID-19 Pneumonia ;
<br />(disease or in)uty MO initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST
<br />.:
<br />d)
<br />1& PART II.OTHER SIGNIFICANT CONDITIONS to the death but in the In PART
<br />I. 19. MEDICAL
<br />-Conditions contributing not resulting underlying cause given
<br />Hypertension, Hyperlipidemia
<br />WAS EXAMINER
<br />OR CORONER CONTACTED?"
<br />re
<br />® YES ❑ NO
<br />0. IF FEMALE:
<br />21a. MANNER OF DEATH
<br />2/b. IF TRANSPORTATION INJURY 21c.
<br />WAS AN AUTOPSY PERFORMED?
<br />Notpregnant within past year
<br />®Natural ❑ Homicide
<br />❑ Driver/Operator
<br />❑YES NO
<br />:.
<br />❑ Pregnant attune of death:
<br />_.
<br />❑ Accident ❑ Pending Investigation
<br />❑ Passenger
<br />WERE AUTOPSY FINDINGS ILABLE
<br />3
<br />❑ Not pregnant, but pnspnant within 42 days of death❑
<br />❑ Suicide ElCould not be determined
<br />Pedestrian 21d.
<br />000
<br />❑ Not pregnant, but pregnant N days to 1 year before death
<br />❑ Other (Specify)
<br />TO COMPLETE CAUSE OF DEATH?
<br />°
<br />C
<br />r
<br />❑....Unknown it pregnant within the past year
<br />❑ YES ❑ NO
<br />229: 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 />I::II
<br />: C
<br />22d. INJURY AT WORK?
<br />DESCRIBE HOW INJURY OCCURRED
<br />v
<br />er
<br />❑ YES ❑ N0,_
<br />122s.
<br />22L LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE Zlf+ CODE
<br />;o
<br />C
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />°
<br />B 5April
<br />8, 2021
<br />B I
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.1
<br />24d. TIME PRONOUNCED DEAD
<br />F }
<br />3
<br />` z
<br />April 9 2021
<br />06:42 PM
<br />d. To On beat of ray knowledge, death occurred at the time, date and place
<br />arra dee to the cause(s) stated. (Signature and Title)
<br />On the basis of examination and/or investigation, In my opinion do" occurred at
<br />the time, date due to the Title) -.
<br />O
<br />u e: 24a.
<br />B
<br />...
<br />and place and causes) stated. (Signature and
<br />z
<br />~'
<br />Zeeshan Khalid, MD9L
<br />~ s
<br />CD
<br />CO USE CONTRIBUTE TO THE DEATH?
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />28b. WAS CONSENT GRANTED?
<br />t_( NO {] PROBABLY ®UNKNOWN
<br />FZeeshan::Khaffd,
<br />❑YES] NO
<br />Not Applicable if 28a is NO ❑YES' ❑ NO ;<:
<br />E AND ADDRESS F CERTIFIER (Type or Print)'
<br />MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE J,,
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />N
<br />April 13, 2021OD
<br />
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