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STATE OF NEBRASKA *am. 41. Atirmasts, .:%4Nrierme WNW ash WHEN THIS COPY CAR RIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BEA 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 2/7/2022 LINCOLN, NEBRASKA E W c 8b. FACILITY -NAME jtf not Institution, give street and number) a;. CHI Health St. Francis 202201847 rte r „0 i Aiti?,. ?-0,41..7:_>�:,�I;k4 rit. SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Howard .::William! Homme 4. CITY AND STATE OR: TERRITORY, OR FOREIGN COUNTRY OF BIRTH Ellsworth, Pennsylvania 7.:SOCIAL:SECURITY::NUMBER 181-34-2355 5a. AGE - Last Birthday (Yrs.) 2 8c. CITY OR TOWN OF DEATH (Include Zip Code) .4 Grand Island 68803 m 9a. RESIDENCE -STATE Nebraska at m 9d STREET {(NO NUMBER 1:508 Spruce Rd 9b. COUNTY Hall 78 5b. UNDER 1 YEAR 2. SEX Male Sc. UNDER 1 DAY MOS. DAYS 8a, PLACE OF DEATH HOSPITAL ®{Inpatient 0 ER/Outpatient ❑ DOA lod. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married 0 Married, but separated ❑ Widowed ❑ Divorced 0 Unknown 11. FATHER S•NAME (First, Middle, : Last, Suffix) John Wesley Homme 9c. CITY OR TOWN Grand Island 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name HOURS MINS. 3. DATE OF DEATH IMo., Day, Yr.) January 17,.2Q22 6. DATE OF BIRTH (Mo., Day, Yr.) August 5, 1943 OTHER ❑ Nursing Home/LTC 0 Decedent's Home 0 Other (Specify) 8d. COUNTY OF DEATH 1 Hall 9e. APT. NO. 9f. ZIP CODE 68801 © Hospice Fac€lity 9g IN8(DE CITY LIMITS'`. YES ❑ NO ." Lorraine Perry 1 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Margaret Elberta Glatfelter 13. EVER IN U.S. ARMEDFORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 07/25/1961-02/29/1984 14a. INFORMANT -NAME Lorraine Homme 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION Burial ❑Donation Cremadori ❑ Entombment ❑ Removal ❑Other (Specify) 16a. EMBALMER -SIGNATURE Stacie L Cook 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Cemetery 17a.FUNERAl HOME.NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island Nebraska 16b. LICENSE NO. CITY / TOWN Grand Island 16c. DATE (Mo„ January 22 2022 STATE Nebraska 171, 880Zip 1Code;; 6, CAUSE OF DE' H See instructions and exam r les 18. PART I. Enter the chain a, events- -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events sucn 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: IMMEDIATE CAUSE (F,nal a) sepsis pneumonia disease oraonditide reeukitlg: in death}::: D'' TO, 3AS A r2S QJENCECF: Sequentially list conditions, if b)lung cancer and immunocompromised any, leading to the causebitted on** a. .. Ener the UNDERGVING CAUSE (dieeaseor injdry3hat initiated the events resulting in death) LAST DUE TO, OR AS A CONSEQUENCE OF: c)Chronic obstructive lung disease DUE TO, OR AS A CONSEQUENCE OF: d) 18, PART Il. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I. 20. IF:FEMALE. Not pregnant within past year ❑ ;Pregnant OLIO* of death ❑>:Not Pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 yearbefore death :: ❑ Unknown if.pregnantwithin the past year • 22e; DATE OFI.NJURY (M. f., Day, Yr.) 22d. INJURY AT WORK? ❑YES „❑NO . 22f. LOCATION:OF I 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident 0 Pending Investigation ❑ Suicide 0 Could not be determined 22b. TIME OF INJURY 21b.IF TRANSPORTATION INJURY !❑ Driver/Operator .❑ Passenger • '❑ Pedestrian ❑ Other (Specify) APPROXIMATE INTERVAL onset to. death Days onset to death Months onset to death Years onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES': ®NO 21c. WAS AN AUTOPSY PERFORMED? 0 YES 123 NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑YES ❑NO 22c. PLACE OF INJURY -At home, farm, .street, factory, office building, construction site, etc. (Specify), 22e. DESCRIBE HOW INJURY OCCURRED NJURY STREET & NUMBER, APT.NO. 23a. DATE OF DEATH (Mo., Day, Yr.) January 17, 2022 CITY/TOWN 23b. DATE SIGNED (Mo., Day, Yr.) January 27, 2022 23c. TIME OF DEATH 08:40 PM 23tl To1he beat of n y knowiedge, death occurred at the time, date and place aitit flus td tris causes) stated, (Signature and Title) The Wut Yee, MD STATE y 24a. DATE SIGNED (Mo., Day, Yr.) to ;S'z P CODE 24b. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) U 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? YES U NO ❑ PROBABLY ® UNKNOWN (3 ADDRESS OF CERTIFIER (Type or Print MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803 27. NAME TITLE AN The Wut Yee 24d. TIME PRONOUNCED DEAD.::.. 24e. Cnthe deals of examination and/or investigation, in my opinion death oCcurretl at the time, date and place and due to the cau e(s) stated. (Signature and•Tkle) • 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES JNO 26b. WAS CONSENT GRANTED? Not Applicable if 28a is NO ❑ YES 0 NO; 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) February 3, 2022 CD CO . <..