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<br />;WHEN "HISCORYCARRIES THE RAISED SEAL OF STATE OF .Af,EBRASO,iifrCERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF,TBE 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 />7x'1412022
<br />LINCOLN, PIEDRA,
<br />+
<br />SARAH 13OHNENKAMP
<br />ASSISTANT STATE REGISTRA
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />777 1.OECEDENV NAME„ (First, Middle, Last, Suffix)
<br />lizabetit AraiGGirmus
<br />CERTIFICATE OF DEATH
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Lawrence,-Nebrask
<br />T;, SOCIAL SEOURITY NUMBER
<br />506.40-2173
<br />tib. PACILITY•
<br />1
<br />CHI Health St. f'tanc
<br />5a. AGE • Lest Birthday
<br />(Yrs.)
<br />ve Street a
<br />inber)
<br />88
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />8a. PLACE QFDEAATH
<br />HO ®
<br />SPfTAL 'hpatlent
<br />ER/Ou patient
<br />ID DOA
<br />DAYS
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Dey'Yr)
<br />OTHER 0 Nursing HomeiLT
<br />❑ Deced
<br />1:3 Other (Sp
<br />8c CITY OR 17.00/f1 OF DEATH (Include Zip Code)
<br />1 Grand Is)and 688#33
<br />1 9a. RESIDENCE -STATE
<br />1 Nebraska
<br />••"::: 9d STREET IIND NUMBS t
<br />389 Ra4taod Roai1
<br />:STATijSAT MTiil
<br />TS
<br />g) ❑ Mauled, but,se
<br />ti 11.?A�rHER'$t1AME;ii
<br />aleltt BBB:. Sit
<br />t
<br />9b. COUNTY
<br />Hall
<br />E QF DEATH ® Married 0 Never Married
<br />Widowed 0 Divorced 0 Unknown
<br />9c. CITY OR TOWN
<br />Grand_ Island
<br />10b. NAME OF SPOUSE (First,
<br />Bobby -D Girmus
<br />13.=RYER IN 18,B, ARMED;FORCES? Glve dates of service ff Yes.
<br />(Yes, No, or Unk) No
<br />15. METHOD OF DISPOSITION
<br />;( Burial , Dtrna*ion
<br />,Ccentat1S2li Enttu ibment
<br />RemovaP ❑ Gibber (Specify)
<br />14a. INFORMANTNAME
<br />Bobby D Girmus
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />lad. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />Middle, Last, Suffix) If wife, gh
<br />syr IN DEorrl PAFf '
<br />10aMARITAL
<br />1 s O.:NST
<br />12, MOTHER'S -NAME (First,
<br />Ida ' Kitten
<br />1Bb. LICENSE NO.
<br />1.` 16d. CEMETERY, CREMATORY OR QTHER LOCA. TION
<br />8 BV Cremation Center
<br />17a FUNENAL.HQME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Llviiitiston Butler V0110d Funeral Home, 1225 N. Elm, Hastings Nebraska
<br />•
<br />111. PART 1. Enter thectio
<br />respiratory arrests
<br />i
<br />IMMEDIATECAUSE(Fh
<br />dlesass ar:oondnion iaau
<br />....... .....................
<br />CITY / TOWN
<br />Hastings
<br />14b. RELATIONSHIP IODIDE Mr
<br />Husband
<br />16c. DATE'(MO., D@y,:Yr.
<br />July 11, 2022
<br />STATE
<br />Nebraska
<br />CAUSE OF DEATH (See:inatruclQrts and examples)
<br />as, injuries, or compucations.hat directly caused the death. DO NOT enter terminal events such asOwen arrest,
<br />Nacho without snowing the etiology. 00. NOT ABBREVIATE. Enter onlyone cause on a line.: Add addalonaHhnelf necessary. "<
<br />IMMEDIATE CAUSE:
<br />a) acute hypoxic respiratory failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, 8: b)Pulseless electrical activity
<br />any: leading to the cause listed
<br />on a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Wee the usixfiunNaoust - c) Pulmonary embolism
<br />• Is (disease Or kdwylhat iatieted
<br />the events re
<br />LAST
<br />king In
<br />1. onset to death
<br />UknoWn
<br />UE TO, OR AS A CONSEQUENCE OF:
<br />1S,<f'ART 11 OTHER StoreF
<br />acute k(dney injuryl n
<br />tT'CONOITIONS-Conditions contributing to the death
<br />olio acidosis, atrial fibrillation, severe sepsis
<br />IF FEMALE ...
<br />Not ptagnentwltMn pest year
<br />Pn*ntnt at16me Otdesti
<br />DADA bud pregnant within 42 days of death
<br />❑ Not pregnant, bud pregnarn 4a days to 1 year before death
<br />Unknown (4preptlant wtdin t)re past year
<br />22e.IaATE OF INJURY (M*., Day, Yr.)
<br />g 22d.^INJURY ATY
<br />V [YES .!❑NO.
<br />22f. LOCATION OF:1
<br />ii
<br />g; In the underlying cause given in PART I.
<br />21a. MANNER OF DEATH
<br />▪ Natural Q Homicide
<br />o Accident ❑ Pending Investigation
<br />❑ Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />2117.IF TRANSPORTATION INJURY
<br />❑ Drt 1enOperator
<br />❑ Passenger
<br />❑ .Pedestolan
<br />❑ Other (Specify)
<br />EXAMINER_'
<br />iONlrACTEo?
<br />1 YE8 ONO
<br />21c. WAS AN A1,e803PBT
<br />_ r P (FORMEp?
<br />❑ YES NO
<br />21d WERE AUTOPSY DINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES Q NO
<br />22c. PLACE OF INJURY.At home; farm, street, factory, office building, construction
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />EET8, NUMBER, APT.NO.
<br />23s. DATE OF DEATH (Mo., Day, Yr.)
<br />July 5, 2022
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />.tela (0 2922
<br />ttl T*: the OA oft ty knowledge, death occurred at the time, date and place
<br />attd des SID* tersse(s) stated. (Signature and Tit.)
<br />Zeeshan Khalid, MD
<br />CITY/TI
<br />23c. TIME OF DEATH
<br />06:04 PM
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD.....
<br />24e Vn the ifasis of examination andlor Investigation, M my opedon de*tit # t
<br />•thetime, date and place and due to the courage) stated. ( : .ssil.
<br />25 DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YES N#3 D PROBABLY`���I UNKNOWN ❑ YES
<br />27 NAME X7 3(5 Ai t3RSSS OF` CERTIFIER (Type or Print
<br />Zeeehan` ha#id,1411D„2620'W Faidley Ave, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />% /Z4
<br />28b. WAS CONSEN
<br />Not Applicable If 26at
<br />28b. DATE FILED BY'
<br />July 13, 2022
<br />pDay, Yr.)
<br />
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