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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 />3/24/2021
<br />LINCOLN, NEBRASKA
<br />A
<br />7
<br />h `.
<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 />!1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Don Keith Roe
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Scotia, Nebraska
<br />?. SOCIAL SECURITY NUMBER
<br />505-35-8827
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (If net Institution, give street and number)
<br />CHI Health St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />204 W 9th Street
<br />9b. COUNTY
<br />Hall
<br />85
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />21 03538
<br />3. DATE OF DEAN (Mo„ Day,
<br />February 15, 2021
<br />6. DATE OF BIRTH (Mo., Day, Yr,)
<br />March 16, 1935.
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />pice Facility
<br />9g. INSIDE GITy LIMITS
<br />(2 YES ' ❑ NO
<br />3
<br />3
<br />'Cr
<br />N
<br />top
<br />b
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married ❑ Never Married
<br />0 Married, but separated ® Widowed ❑ Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Orville A Roe
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />112. MOTHER'S -NAME (First,
<br />Margaret L Collins
<br />14a. INFORMANT -NAME
<br />Tom Roe
<br />Middle, Maiden Surname)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />0 Cremation 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Beniamin Hall
<br />16b. LICENSE NO.
<br />1305
<br />16c. DATE (Mo., Day, Yr.)
<br />February 15, 2021
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Nebraska Anatomical Board
<br />CITY / TOWN
<br />Omaha
<br />STATE
<br />Nebraska
<br />(1Ta. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Nebraska Anatomical Board 986395 Nebraska Medical Center, Omaha, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. 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,
<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 />IMMEDIATECAUSE(Final ; a) Hypoxic Respiratory Failure
<br />disease or condition: resulting
<br />In death) _ DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, it b)Acute On Chronic Systolic Congestive Heart Failure
<br />any, leading to the causelisted
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE. c) Ischemic Cardiomyopathy
<br />(disease "or injury that inRtaterl
<br />17b. Zip Code
<br />68198-6395
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Days
<br />onset to death
<br />Days
<br />the swots resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST _.. __... d)
<br />18. PART II, OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Achalasia, Hypertension, Obstructive Sleep Apnea
<br />20. IF FEMALE:
<br />❑
<br />Not pregant within past year
<br />0 Pregnant at time of death
<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 />0 Unknown if pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES No
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify}
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION Of INJURY STREET & NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 15, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />February 18, 2021 02:58 PM
<br />224. Td ttq bete Of my knowledge, death occurred at the time, date and piece
<br />and due to the cause(s) stated. (Signature and Title)
<br />Vinay K. Singh, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP CODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or Investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Tae)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES '❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Vinay K. Singh, MD, 2620 W Faidley Avenue, Grand Island, Nebraska, 68803
<br />26a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 19, 2021
<br />i
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