|
a 1 \ 11 l 5 \ 11 Ill 11� 11 11 I
<br />�1 //ie \ 1111 \11 11 t 11 I ,\ I \1 1111 y
<br />� \ l 6 1 y�� 1 11 ,rnP , I n \ ( III nr I
<br />a II nr 1 rr . ` (111 elfu�u...lau.�uuue..Irldme....a 111) ivl.,S.14F.nna\.,�uu. lel p r11. 1 I n
<br />{tZlr/NN\ 1111jlllll(ry{S/f(N dll��)"1)ulll((./Il,�dd.1ia�S _ ._____..�.. 1141e111➢ 11111�11illli£6frM 1Aii))111
<br />STATE OF NEBRASKA
<br />dulA,ij je) 17r1r111111v�� 4dQll��r%i. n 11w 11 �.p4�1 lleiil1,.11�iyI eMr t )p)err�
<br />rrrl '�f11w11yS Ir.1,444Vdp11 ;, 1594tlhAlINSS rSlluPlla - IdWAV.r11115f ` �I144MIn1 - yf(1 11111u 11„ rl
<br />IeVegl \N1 n �ol/r�s )tldi/+tr
<br />". y({i(VrN, @1,i11iilr If U✓M,'i�)))I+:,i (t
<br />'
<br />,�+'� 1it;t1t edr' 17)„ei+
<br />INN r,,nret 111)11
<br />WHEN THIS COPY CARRIESTHE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OFTHE ORIGINAL RECORD ON FILE WITH THE E NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE f3 (a^ BANG.
<br />6/23/2022
<br />LINCOLN, NEBRASKA
<br />202205`152
<br />DECEDENT'S NAME (Fiat Middle,
<br />Brenda :Kay Astrones
<br />t44-17&kitart;
<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 />Last,
<br />Suffix)
<br />CERTIFICATE OF DEATH
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Germany
<br />St3CIAL SECt,IRITY NUMBER
<br />805 7649486
<br />5a. AGE - LastBirthday'
<br />(Yrs.)
<br />67
<br />Sb.. FACILITY -NAME (If not Institution, give street and number)
<br />CFit,.:H
<br />Sc CITY OR TOWN OFDEATH (Include Zip Code)
<br />Grand Island 88803
<br />Se. -RESIDENCE -STATE
<br />Nebraska
<br />9d ?STREET AN'D NUMBER
<br />209 W Wait Avenue
<br />(lb. COUNTY
<br />Hall
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />84•:PLACE OF DEATH •
<br />HOSPITAL Inpatient
<br />❑ ER/Outpatient
<br />DOA
<br />9c. CITY OR TOWN
<br />Doniphan
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Ma,
<br />June 12,3022 .:
<br />6. DATE OF BIRTH (Mo., Day, Yr)
<br />January
<br />OTHER 0 Nursing Home/LTC
<br />o Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />ce Fadi#hr
<br />ee. APT. NO.
<br />9f. ZIP CODE
<br />68832
<br />9g iMSIE1E CkTY Liitrs;
<br />'.yrs _ 'Q.
<br />10a. MARITAL`
<br />0 Married;'
<br />rATUs AT TIME OF DEATH 0 Married 0 Never Married
<br />separated , Widowed 0 Divorced 0 Unknown
<br />41. FATHER'S -NAME (Find, Middle, Last, Suffix)
<br />40llan Henry. :D(bberly
<br />13. EVERIN U SrARMEc FORCES?.
<br />' (Yea No or.Nnii.) No
<br />1b. METHOD 0 DISPOSITION
<br />auriai t3pon00on
<br />Cremation 0 Eftcdrtbment
<br />Removal. ':Q Other tspec/fy
<br />; 31ve dates: ofservice If Yes.
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife,; give maiden ei
<br />David Ronald Astrones
<br />14a. INFORMANT -NAME
<br />Stephanie Roach
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />12. MOTHER'S -NAME (First,
<br />Lois Jean Mays
<br />16b. LICENSE NO.
<br />1454
<br />Middle, Maiden Surname)
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Ceetarview Cemetery Doniphan
<br />17a. FUNERAL Home NAME AND MAILING ADDRESS (Street, City or Town, state)
<br />Ail Faiths Funeral Home, 2929 S. Locust Street, Grand Island,; Nebraska
<br />CAUSE OF DEATH' (See instructions and examples)
<br />PAgI' J. Einer tate chain of even s- .disaesas, injuries, or complications-thatdirectly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arreati or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines If necessary.
<br />14b. RELA'
<br />Daupht
<br />SHIP TO DECEDEN'
<br />16c. DATE (Mo. Day,'Yr.),
<br />June 96, 21122.
<br />ATE'
<br />IMMEDIATE CAUSE:
<br />IftWSDIATE0040EIFhI8) a)Acute Respiratory Failure with Hypoxemia
<br />41040dr ra 14.XiOrt re5d, PS
<br />'DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list ConditIons. if b) Hypersensitivity Pneumonitis-?Kisgali
<br />eny.lserJit?g to too cause sow
<br />an linea
<br />?it,* Ut3IYa
<br />4diseaee or mju
<br />the events resu
<br />BAST
<br />Vdi'CAUSE
<br />t initiated
<br />In death)
<br />TO, OR AS A CONSEQUENCE OF:
<br />tastatic.breast cancer - possible lyii phang tic c
<br />qk Y(p;Douala
<br />68801 :::
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 PART f men S)GNEHCANt CONDITIONS-Condltions contributing to the death but nM res uKing in the underlying c
<br />Pulmonaryemphysema,Hypertension, Pancytopenia due to cancer treatment, GERD
<br />use given In PART I.
<br />19. WAS IJMED10At. EXAMINER
<br />OR <ONTACTED?
<br />❑ YES' ®NO
<br />2(J. IFFEMALE
<br />Nat pregnxnt:w)thin pass e(
<br />j Freynaat anima of.
<br />pregnant, bin pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown if pragneht whin ate past year
<br />21a. MANNER OF DEATH
<br />1a Natural ❑ Homicide
<br />❑ Accident ❑ Paftdittg Inveatigatton
<br />❑ Suicide ❑ Could not be del ,lned
<br />21b IF TRANSPORTATION INJURY
<br />Qorlveroperetor
<br />© Psesenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOF
<br />Q YES
<br />PERFORMED?
<br />21d. WERE AUTOPSY F INDINGS AVAILABLE
<br />E
<br />TO COMPLY CAUSE OF DEAN?
<br />0 YES ❑ 140 :::...
<br />•PATE C i !N,i ArirN
<br />Yr.)
<br />22b. TIME OF INJURY
<br />22c PLACE?OF INJURY.At name, .farm, sheet, factory, office building, construction i
<br />22d. INJURY AT WORK?
<br />12
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />....................
<br />ET & NUMBER, APT.NO.`,
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />Jane 12, 2022
<br />23b DATE SNJNED {Ma; Day, Yr.)
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />09:55 AM
<br />tW... TO the best Of my knowledge, death occurred at the time, date end place
<br />ant( **tome Cause(s) stated. (Signature and Tlne)
<br />Kimberly A. Mickels,,MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PR(
<br />44 ED:
<br />w r•y:.
<br />24e. Cn the basis of examination and/or Investigation, In my opinion deaftl fraattr'red et
<br />the time, date and place and due to the cations) stated. (Signature and This)
<br />2L DID TOSACtr'O USE 00NTRtBUTE TO THE DEATH? N`:O
<br />YES ❑ NO i3 PROBABLY 0 UNKNOWN
<br />27NAME, TAU;AND A.._..REtf'S OF CERTIFIER (Type or Print
<br />Kimberly A. MTCkels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />26a. HAS ORGA
<br />❑ YES
<br />R TISSUE DONATION BEEN CONSIDERED?
<br />NO
<br />26b. WAS CONSENT GRANTED'
<br />Not Applicable if 26a is NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr..
<br />June 21, 2022
<br />
|