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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />12/7/2021
<br />LINCOLN, NEBRASKA
<br />C.3
<br />are find with the county cool
<br />2022004t0
<br />SARAH BOHNENKAMP l
<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 />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Tammy Joye Holder
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507-90.7962
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Brvan Medical Center East
<br />86. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Lincoln 68506
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER:
<br />4079 Stauss Rd
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH El Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />60,
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL Inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />10b. NAME OF SPOUSE (First,
<br />James Holder
<br />HOURS
<br />MINS.
<br />21 16383
<br />3. DATE OF DEATH (Mtn , Day, Yr)>.
<br />November 24,.2021
<br />6. DATE OF BIRTH (Mo., Day, Yr.)'
<br />December 16, 1960
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />led. COUNTY OF DEATH
<br />Lancaster
<br />Pe. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />Q Hospice Faadlity
<br />9g. INSIDE CITY LIMITS
<br />® YES O. NO
<br />Middle, Last, Suffix) If wife, give maiden name
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) j 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Allen SCttultz
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />James Holder
<br />Pauline Snyder
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑ Bahia! ❑ Donation
<br />® Cremation 0 Entombgtent
<br />❑Removal ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />16b. LICENSE NO.
<br />1495
<br />CITY I TOWN
<br />Gibbon
<br />16c. DATE (Mo., Day, Yr.)
<br />December 22, 2021
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />AII Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />1e. PART I. Enter the chain of events- -Ms , Injuries, or complicatlons4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or verdricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a tine. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE cause (Pinot a) Cardiac arrest
<br />disease ordandltion resulting
<br />In distil)
<br />Sequentially list conditions, M
<br />any, leading to the cause listed
<br />on line it.
<br />ErnstYhe UNDERLYING CAUSE.
<br />(disease er injury:t!at Initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Hemorrhagic shock
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />c) Gastrointestinal bleeding
<br />17b. Zip Code
<br />68801`
<br />APPROXIMATE INTERVAL
<br />onset to deatdt;;:
<br />4 Hours
<br />onset to death
<br />12 Hours
<br />onset TO -death
<br />12 Hours
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II.OTHER SIGNIPtCANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />COVID 19 pneumonia, left leg deep venous thrombosis
<br />onset to death
<br />19. WAS MEDICAL.EXAM)NER ,
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE:
<br />Met pregnant within pest year
<br />❑ regnant n Saw of Wath
<br />0 Not pregnant but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown H pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />OYES ❑ NO,,
<br />21a. MANNER OF DEATH
<br />El Natural ❑ Homicide
<br />❑ Accident 0 Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />® NO
<br />❑ YES
<br />21d. WERE AUTOPSY F#NO(NGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, sty. (Speen
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22r. LOCATION OF INJURY -STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />1
<br />0.
<br />11
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 24, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />November 24, 2021 06:35 AM
<br />23d. To the best of my knowledge, death occurred at the time, dare and place
<br />end:tlw to the causes) stated. (Signature and Title)
<br />Anne Perlman, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES Ea NO 0 PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE! AND ADDRESS OF CERTIFIER (Type or Print
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or Investiga ion, In my opinion death ettuttedatt
<br />the tiros, date and place and due to the cause(s) stated. (Signature and /Me)
<br />26a. HAS ORGAN QR TISSUE DONATION BEEN CONSIDERED?
<br />El YES ❑ NO
<br />Anne Penman, MD, 1600 S 48th St, Lincoln, Nebraska, 68506
<br />285. REGISTRAR'S SIGNATUREt t'
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO j YES ❑ NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 1, 2021
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