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1r�Ity/N.,N�t2tt@AXFIdIXt74kT5If�(4ddt3\t�.Otit��t�iiiGrr7,.e.W�ld�itt03R'f1445'Y3�la4 dti��iFlatit�lt7'l7Sfy �.: STATE OF NEBRASKA Iia Rtafaaaatr attMtg4iMMftis3tr° +lstttpgq,txr tdtM444tXilIlN4tta ; ,47It,t,,n,» t,i41ti, Sl 7 ntrF1e1a1ul3 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 2/2/2021 LINCOLN, NEBRASKA 202108289 8 ;gib, I,th a 4.y'tzaketryt ` SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 21 00926 V 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Abel Santos 2. SEX Male 3. DATE OF DEATH MO., .Day, Yr.) January 18, 2021 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Scottsbluff, Nebraska 5a. AGE - Last Birthday (Yrs.) 67 5b. UNDER 1 YEAR 5c. UNDER 1 DAY MOS. DAYS HOURS MINS. 6. DATE OF BIRTH (Mo., Day, Yr.) February 2, 1953 7. SOCIAL SECURITY NUMBER 505-66-2183 Ob. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9d, STREET AND NUMBER 238 N Carey Street 9b. COUNTY Hall 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island OTHER 0 Nursing Home/LTC ❑ Decedent's Home ❑ Other (Specify) I8d. COUNTY OF DEATH Hall 9e. APT. NO. 9f. ZIP CODE 68803 {i Hospice Facility 90, INSIDE CITY LIMITS 5a YES ONO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Dorothy Mae Cole 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Jesus Santos Concha Hernandez 13. EVER IN U.S, ARMED FORCES? Give dates of service If Yes. (Yes, No, or Link) No 14a. INFORMANT -NAME Dorothy Mae Santos 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑'Burial 0 Deflation igt Cremation ':❑ Entombment 0 Removal ❑ Other (Specify) 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) January 19,2021; 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 688001 CAUSE OF DEATH (See instructions and examples) 1e. PART I. Enter the chain of events- diseases, Injuries, or complications -hat 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 If necessary. IMMEDIATE CAUSE: a)Acute Hypoxic Respiratory Failure IMMEDIATE CAUSE (Final disease or condition resulting Sequentially list conditions, if any, leading to the cause listed on line a. Enter. the UNDERIVINOEA1)SE (diserni or injury that initiated the events resulting in death) LAST in to A E .4i! a 0 G4 m E d S 541 r o 5 Le a0 0. DUE TO, OR AS A CONSEQUENCE OF: b)Acute Respiratory Distress Syndrome APPROXIMATE INTERVAL onset to death Unkown onset to death DUE TO, OR AS A CONSEQUENCE OF: C) COVID 19 onset to death DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 18. PARTS. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I. Atrial Fibrillation, Diabetes Mellitus 2, Hyperlipidemia, Obstructive Sleep Apnea, Morbid Obesity 19. WAS MEDICAL- EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 20.1F FEMALE: ❑ Nut pregnant within peat year ❑ pregnant at time of death 0 NOt pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death 0 ,Unknown S pregnant within the past year 21a. MANNER OF DEATH Natural 0 Homicide 0 Accident 0 Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger 0 Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 1 NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑NO 22e, DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, IC. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) January 18, 2021 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH January 19, 2021 07:00 PM Sad. Td the beat of myknowledge, death occurred at the time, date and place endue tante cause(s) stated. (Signature and This) Zeeshan Khalid, MD 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 24e.On the basis of examination and/or investigation, in my opinion death occurred* the time, date and place and due to the cause(s) stated. (Signature and Title) 28. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES ❑ NO 0 PROBABLY ® UNKNOWN 28a. HAS ORGAN OR 0 YES SSUE .. El NO ATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ' ❑ YES ❑ No 21. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Zeeshan Khalid, MD, 2620 W Faidley Ave, Grand Island, Nebraska • e 28a. REGISTRAR'S SIGNATURE Gt/I2}3 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) January 26, 2021 01 O