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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 />9/13/2021
<br />LINCOLN, NEBRASKA
<br />20210809 L 6:fAiunkitfyf�
<br />SARAH BOHNENKAMP i
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICAT
<br />21 11417
<br />Pursuant to section 30-2413, demands for notice which may affect the estate Of the deceased are Bled with the county court in the county where the decedent resided at the time of death.
<br />1. DECEDENTS«NAME (First, Middle, Last, Suffix)
<br />Isadore Louis Breault
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day.Yr.)
<br />August 26, 2021
<br />4. CITY AND STATEOR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo.,, Day, Yr.)
<br />St. Joseph, Kansas
<br />(Yrs.)
<br />89
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />October 30, 1931
<br />7. SOCIAL SECURITY NUMBER
<br />515-26-8116
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient OTHER 0 Nursing Home/LTC [
<br />Hospice Facility
<br />8b. FACILITY -NAME (Knot Institution, give street and number)
<br />CHI Health St. Francis
<br />0 ER/Outpatient 0 Decedent's Home
<br />❑ DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1623 West Charles Street
<br />Ie. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY UNITS
<br />® YES 0 NO
<br />10a, MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed ❑ Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Patricia Baker
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Louis Breault
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Eva Boulev
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service N Yes.
<br />(Yes, No, or link.) No
<br />14a. INFORMANT -NAME
<br />David Breault
<br />14b. RELATIONSHIP TO DECEDENT'
<br />Son
<br />15. METHOD OF DISPOSITION
<br />°Burial ['Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />August 30, 2021
<br />cremation ©Entombment
<br />Removal 0
<br />Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Apfet Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />13. 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 />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without shoving the etiology. DO NOT ABBREVIATE. Enter only one cause on a Zine. Add additional Imes if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Pinel : a) Cardiac Arrest
<br />disease or condition resulting 4'
<br />onset to death
<br />Minutes
<br />m death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b) Ventricular Fibrillation
<br />any, leading to the cause listed
<br />line
<br />onset to death
<br />ond.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Einer the UNDERLYING CAUSE C)
<br />(disease or injury: that initiated
<br />onsettc death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />16. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Septic Shock, Acute Hypoxic Encephalopathy, Acute Hypoxic Respiratory Failure
<br />19. WAS MEDICAL- EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE:
<br />0 Not pregnant within pest year
<br />0 Pregnant at time of deathPassenger
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />❑ Net pregnant, but pregnant within 42 days of deathsuicide
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />❑ ❑ Could not be determined❑Pedestrian
<br />0 Other (Specify)
<br />21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Moi, Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (8pecIfy)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION: OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />a 1
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 26, 2021
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />1 }
<br />i g
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />AuQust 30, 2021
<br />23c. TIME OF DEATH
<br />02:19 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />o
<br />6
<br />o El
<br />2
<br />3d. To the beet of my knowledge, death occurred at the time, date and place
<br />and due to aro cause(s) stated. (Signature and Title)
<br />Suresh Manapuram, MD
<br />24e. On the basis of examination and/or investigation, In my opinion death mum d at
<br />the time, date and place and due to the cause(s) stated. (signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable H 28a is NO DYES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Suresh Manapuram, MD, 2620 W Faidley Ave,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE�p
<br />ok� 8.01--iz-Aao-tn-
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 1, 2021
<br />CD
<br />410
<br />01
<br />C,
<br />
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