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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 />10/13/2020
<br />LINCOLN, NEBRASKA
<br />202108175
<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 />2013398
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed 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 />Virginia Ann Pokorski
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />October 6, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />Loup City, Nebraska
<br />(Yrs.)
<br />78
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />May 25, 1942 ;.
<br />7. SOCIAL SECURITY NUMBER
<br />505-54-4560
<br />8a. PLACE OF DEATH
<br />HOSPITAL 1:1 Inpatient OTHER 0 Nursing Home/LTC Hospice Faculty'
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHl Health Bergen Mercy
<br />❑ ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY CR TOWN OF DEATH (Include Zip Code)
<br />Omaha 68124
<br />8d. COUNTY OF DEATH
<br />Douglas
<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 />2116 N. Sheridan Avenue
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9.2. INSIDE CITY (IMITS'
<br />® YES ❑ NO
<br />10a, MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />❑ Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Patrick Reynold Pokorski
<br />'11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Edward A Shotkoski
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Anna H Eurek
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) No
<br />14a. INFORMANT -NAME
<br />Rodney L Pokorski
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />15. METHOD OF DISPOSITION
<br />®"curial [j Donation
<br />16a. EMBALMER -SIGNATURE
<br />Andrew D Purcell
<br />16b. LICENSE NO.
<br />1486
<br />16c. DATE (Mo„ Day, Yr.)
<br />October :13, 2020
<br />©;Cremation 0 Entombment
<br />❑ Removat ' 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Our Lady of Mount Carmel Catholic Cemetery Paplin Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Peters Funeral Home, 302 Second Street, PO Box 181, St. Paul, Nebraska
<br />17b. Zip Code
<br />68873
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events- -diseases, injuries, or complicationsahat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE Fimal a) Right Heart Failure
<br />disease or condition resulting
<br />onset to death
<br />1 Week
<br />in death} DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, If b) Pulmonary Hypertension
<br />any, leading to thecauselisted
<br />fine
<br />onset to death
<br />on a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />EMer:the UNDERLYING CAUSE C)
<br />(disease or Injury that initiated - -
<br />onset todeath
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />IL FART II. OTHER SIGNLFtCANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />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 past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ® NO
<br />❑ Not pregnant, but pregnant within 42 days of deathCould
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />Suicide not be determined
<br />❑ 0
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21d. WERE AUTOPSY' FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES ❑ NO
<br />22a. DATE OFLNJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, stn. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f, LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be completed by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 6, 2020
<br />b _
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />October 8. 2020
<br />23c. TIME OF DEATH
<br />09:40 AM
<br />V 124c.
<br />3
<br />PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and duel() the cause(s) stated. (Signature and Title)
<br />Shraddha Narechania, MD
<br />u re Z
<br />$
<br />B O $
<br />~ 3 a
<br />2M. On the basis of szamination andlor Investigation, In my opMion death occurred at
<br />the time, dab and place and due to the cause(s) staled. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES IJ NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES til NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a Is NO ❑ YES 0 NO
<br />2T. NAME, TITLEAND ADDRESS OF CERTIFIER (Type or Print
<br />Shraddha Narechania, MD, 7710 Mercy Rd, Omaha,
<br />Nebraska, 68124
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />October 8, 2020
<br />28a. REGISTRAR'S SIGNATURE �l
<br />_,4L__• d(-/ "" • ''
<br />
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