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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF roe 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 OP ISSUANCE
<br />6/15/2022"
<br />LINCOLN, NEBRASKA
<br />E
<br />202205041
<br />SARAH BOHNENKAMP" T%
<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. DECEDENT!$ -NAME (First, Middle, Last, Suffix)
<br />diary Albert Ummel
<br />4. CITY ANDSTATE OR -TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />17.;SOCIAL .SECURITY NUMBER
<br />506«58-8339
<br />m
<br />8b:.FACILITY NAME (f 1nCt institution,
<br />CHI Health St. Francis
<br />.street and number)
<br />tiC. :qTY OR TOWN OFDAT-ii
<br />(include Zip Code)
<br />Grand Island 88803•
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d,STREETAND NUMBER
<br />1::723 St :Paul RoRd
<br />9b. COUNTY
<br />Hall
<br />8a AGE - Last Blrthgay:
<br />(Yrs.)
<br />5b, UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OPDEATH
<br />HOSPITAL ,I; Inpatient:
<br />0 ER/Ou patient
<br />0 DOA
<br />HOURS
<br />MINS.
<br />22 08299
<br />3. DATE OF DEATH (Mo.(I ffil Yr)
<br />May 19, 22::`
<br />6. DATE OF;BIRTft(Mo.,
<br />May 13, ):fa47:;:;:,::.
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedenrs Home
<br />❑ Other (SpecRY)
<br />10a MARITAL:$TATUSA7.TIME OF DEATH ® Married ❑ Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />11 FATHER`S.NAME• (FIr84
<br />Albeft Ummel !:
<br />Middle,°. Last, Suffix)
<br />13,:EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD`OF DISP'OSIBON
<br />Burial [Donation
<br />14,1 CrO.MatiOrK QEntombment
<br />{ Removal ❑ Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />De. APT. NO.,
<br />lob. NAME OF SPOUSE (First, Middle, Last,
<br />Estel
<br />9f. ZIP CODE
<br />68801
<br />Bove
<br />12, MOTHER'S.NAME (First, Middle,
<br />Alice: Lacey
<br />14a. INFORMANT.N4ME
<br />Este/ Ummel
<br />18a. EMBALMER -SIGNATURE
<br />Tracey Dietz
<br />16b. LICENSE NO.
<br />1328
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Jacobsen Greenway -Dietz Funeral Home, 411 0 Street, PO Box 112, St, Paul,, Nebraska
<br />CITY I TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instruction. and examples)
<br />. PART I.'Enler the chaindiverts- dlseaaee,injuries, or complications -that 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 one line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IW4EDIA7&cat✓ E(Finel a) Acute hypoxic and hypercapneic respiratory failure
<br />d(sasseor..ridden.te elthig ." ...
<br />INSIDE CR'Y' LIMITS,
<br />1 Yds . ❑ <M0 ::'
<br />14b. RELATIONSHIP TO'.
<br />Spouse ,
<br />16a. DATE me„ Dey,,;Yr.)
<br />May 26, 2022
<br />as
<br />yx In deettd DUE TO, OR AS A CONS
<br />to Sequentially list conditions, if
<br />any, leading to the cause eeted
<br />on'iinea
<br />Falter theUpatig .YINktCAUSE
<br />�'... (disea6aor Injury that fnfaeted
<br />the events resulting in death)"
<br />is LAST
<br />EQUENCE OF:
<br />b)TraumatiC Acute Subdural Hematoma
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />pus TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />Acute encephalopa;tty COPD, Seizure
<br />20. IF FEMALE::
<br />❑ NotpregquntWithlfDBs#r
<br />Pregnain at ineof death:..
<br />Q Nat pregtwnt, but pregnantwithin 42 days of death
<br />0
<br />Not pregnant, but pregnan143 days tot year before death
<br />❑.; Unknown it...pregnantvddrin the past year
<br />22* DAT OF I
<br />URY (MO
<br />22d. INJURY AT WORK?
<br />❑YES [3 NO
<br />21a. MANNERQF DEATH
<br />Natural a Monficide
<br />❑ Accident ❑ ae ding ravesdgatfon
<br />0 Suicide 0 Could not be determined
<br />Day, Yr.) 22c. PLACE OF
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22b. TIME OF INJURY
<br />NJURY4it
<br />::STATE.'
<br />Nebraska
<br />l7b Zlp:!CodP"
<br />*140e.
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />El Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />home, farm,
<br />onset to death
<br />19. WAS MeettlA1 EXAMINER,„: ...
<br />OR COOONTAC.TEO?
<br />❑ YES • NO
<br />21c..WAS AN AUTOPSY Pt( QRi
<br />❑ YES 1 NQ
<br />P
<br />18 ART Il OR S
<br />THEIGNIFICANT CONDITIONS -Conditions contributing to the death but not reoult ng ht the underlying cause given In PART I.
<br />21d. WERE AUTOPSY AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />•
<br />❑ YES
<br />rest, factory, office building, construction site, :(8
<br />21'. LOCATION OF INJURY.. STREET & NUMBER, APT.NO. CITYITOVWN
<br />:'DATE OF DEATH (Mo., Day, Yr.)'
<br />May 19, 2022
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />June 14, 222 05:20 PM
<br />d Triebe bestof my pnowletlge, death occurred at the time, date and place
<br />DTIC due to gttgause{s) stated. (signature and Titie)
<br />Suresh Manapuram, MD`<
<br />25. Dip TOBAC.CO USE CONTRIBUTE TO THE DEATH? < 28a. HAS ORGAN QR TISSUE DONATION BEEN CONSIDERED?
<br />YES ;i�YI NO ]PROBABLY. 0
<br />STATE
<br />} 24a.' DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH"
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />14e. On the besis'of examination and/or investigation, in my opbtton,
<br />:1111).000.; date and piece and dire to the causes) stated. (Slgnaterre
<br />UNKNOWN ❑
<br />YES.'..'!
<br />2f NAME, TITLE AND ADDRESS OF CEterIFIER (Type or Print
<br />Suresh Manapuram, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED'?::::.
<br />Not Applicable If 28a Is NO
<br />28b. DATE FILED BY REGIST (Mo., Day, Yr.)
<br />June 15,2022
<br />
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