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<br />STATE OF NEBRASKA
<br />�G//trANtllle a_./It1911ff1NDftpx Yr94'iSMDta .%AaI1lTftifDD?1?
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<br />WHEN rows COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA 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 />J DATE:QF:ISSUANCE
<br />4/27Q022
<br />LINCOLN, NEBRASKA'
<br />20220378b
<br />it�t,/Fd�. 7 ,ti-r� �:rT, t fit,
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />`TATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />{. bedspeNTS,NAME (First,
<br />Delores .:Lorraine: Om
<br />ast, Suffix)
<br />4. C17Y AND STATE QR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Palmer, Nebraska..
<br />7. SQCIAL SEcURI
<br />608-42-3283
<br />;NUMBER
<br />6a. AGE - LastEirthday:
<br />(Yrs.)
<br />8b. FACILITY -NAME (if not Institution, give street and number)
<br />112'w The Heritage at Sagewood
<br />$c CITY OR TOWN OF DIAATH (Include Zip Code)
<br />Grand Island 58803
<br />9a.'RESIDENCE-STATE
<br />'
<br />Nebraska
<br />8d. Si'REET AND NUMaEtti
<br />30411 t E3th atreetl'
<br />9b. COUNTY
<br />Hall
<br />109. MARITAL STA TU11 AT TIME OF DEATH 1 Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />11. PAVER'S-NOME (PIM,
<br />Alfred Meyer
<br />Middle, Last,
<br />Suffix)
<br />13;14E164 laARMED'FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit.) No
<br />16. METHOD OF DISPDSITION
<br />P;'Burfat ❑ Dttnallon
<br />❑Cremation: ❑ Entombment
<br />Q'Removal ❑ Other (Specify)
<br />85
<br />3b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL f j Inpatient
<br />�] ERIOu patient
<br />9c. CITY OR TOWN
<br />Grand Island
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />HOURS
<br />MINS.
<br />3. OATE.OF DEAT}i (Mo, Dap Yr);.
<br />April 16, 2t%
<br />6. DATE OF BIRTH f910., Day, Ye.)
<br />January &1937:.<.
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />Ea Other (Specify)ASSISTED LIVING
<br />•
<br />ce FaotSty,
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />lab. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, glv
<br />Marion Dale Omel
<br />14a. INFORMANT -NAME
<br />Marion Dale Omel
<br />16a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />CsITYLIMITE:
<br />❑ X10 'r
<br />12. MOTHER'S -NAME (First, Middle, MaldenSumaine)'
<br />Evanpelins > Lorraine Schwarz
<br />I8d; CEMETERY, CREMATORY OR OTHER LOCATION'
<br />Grand Island City Cemetery
<br />17a.,FUNErRAL,FIOME NAME AND MA LING'ADDRESS (Street, City or Town,:State. )
<br />Ali Faiths Funeral H'pme,.2929 S: Locust Street, Grand Island, Nebrask_,
<br />16b. LICENSE NO.
<br />1397
<br />CITY / TOWN
<br />Grand Island
<br />14b. RELATIONSIBP TO PacEBEN'r
<br />Spouse
<br />16a.. DATE (Mo _Day, Yr )
<br />April 21,
<br />S�'AIZ
<br />ebreska
<br />1P4.20Code.:
<br />88801
<br />CAUSE OF DEATH (Seo Instru
<br />ion's and examples)
<br />18. PART I. Enter the Chain of ev8ilte. -diseases, ihJurias, or complications -that directly caused the death. DO NOT enter terminal events: such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without Showing die etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add addhlonal lines 4 necessary... IMMEDIATE CAUSE:
<br />a) advanced dementia
<br />IMfdEDIATECAtJttEtPhini
<br />• diesase oreondr[oo retuning.
<br />to dea6a2 DUE TO OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, If b)
<br />.::any, leading to the cause listed
<br />on :ltrle a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />EntertheUNDe LY1NOCAUSt C)
<br />oblates:ea injury that Initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST .. _ d)
<br />18 PART II_o7 R.$1 NIFICANT CONDITIONS -Conditions contributing to the death but not.resufNng'
<br />3O. IFFEMALE; :;:.
<br />Not P1agnant;witMe pea
<br />t+regn8rdat1lmeattlaadt
<br />❑ tJotptegnaitt butpregnantvd
<br />❑ Not pregnant, but pregnant 48 days to 1 year before death
<br />. ❑„Unknown if pregnent.within the Met year -
<br />hit, 42 da+
<br />22i6tATE Or•IN uRY
<br />}Mots Day, Yr.)
<br />22d. INJURY AT WORK?
<br />OYES ©NO:::;:.:
<br />21a. MANNER OF DEATH
<br />L Natural ❑ Homicide
<br />❑ Accident ❑ Pendipg Invedtigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE<OF IN
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22E.LOCATION OCATION'0 INJURY: STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yc)
<br />April 16, 2022
<br />CITYITOWN
<br />23b. DATE SIGNED (Mo.; Day, Yr.) 23c. TIME OF DEATH
<br />All ;0,2022 06:10 AM
<br />TOthe, beetbf my knowtedg6.;deat6occurred at the time, date and place
<br />and duata the tasse(s), atate4lsignatura and Title)
<br />Chandrakumaran Anchalia, MD
<br />6. DID <TOBACCO USE CQNTRIBUTE TO THE DEATH?
<br />:.❑ YES NO ❑ PROBABLY ❑ UNKNOWN
<br />27. NAME, n'r(E AND ADDRESS OF CERTIFIER (Type or Print
<br />Charidrakumaran'Anchalia, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />pie underlying cause given In PART I.
<br />21h, IF TRANSPORTATION INJURY
<br />D Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />'.❑
<br />Other (Specify)
<br />18. WAS MEM , EXAMINf»R
<br />OR cORONER:CONTACIED?
<br />❑
<br />YE s SI NQ
<br />21c. WAS AN'AUTt
<br />CI Yea
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES 0 N
<br />URY-At home, farm, street, factory, office building, construction at
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />240. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />245. On the tresis of examination and/or Investlga Ion, in my opintan'deatlt tt4611tn
<br />810:8155, date and place and due to the causes) stated. ($ilSnaps)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />28a. REGISTRARS SIGNATURE
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a is NQ 0 YES
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 20, 2022
<br />
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