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<br />STATE OF NEBRASKA
<br />WHEN /S COer: CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERT/Fids THE DOCUMENT SELO
<br />BEA TRUE CO "Y O.F THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMANSERVIIES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEposiroRyFOR VITAL RECORDS
<br />LATE OP ISSUANGI
<br />6/17/2022
<br />LINCOLN, NEBRASKA
<br />2022'06598
<br />irm
<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 />CERTIFICATE OF DEATH
<br />1. DEOEDBNrS NAME {#+fret, Middle, Last, Suffix)
<br />Michael Palu ..
<br />A CITY AND STATEt7
<br />ERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />rand island, N
<br />ska
<br />I. soma SECURITY NUMSER
<br />505-(W1167
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />4019 Kay Ave
<br />crry OR TO f N OF DEATH (include Zip Code),
<br />•
<br />Ont islantt'S O3'
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />t d. STREET AND NUMBER:::::
<br />4019 KSY Ave
<br />Sa. AGE - Last:Birthday:
<br />(Yrs.)
<br />. 63
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. CINDER / DAY
<br />MOS.
<br />DAYS
<br />Ba PLACE OF DEATH
<br />HOSPIT�--+AL ] tripadant
<br />0 ER/Outpatient
<br />❑ DOA
<br />9b. COUNTY
<br />Hall
<br />AR TAL STATUSR.T TIME OF DEATH l Married 0 Never Married
<br />Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S*NAME (First, Middle, Last, Suffix)
<br />Elvin Palu
<br />13. EVER IN U.S1 ARMIID FORCES? Give dates of service if Yes.
<br />,(Yes,. No, or Link) NO
<br />18.:METHOD OF DISPOSITION
<br />C Huriai El Donation
<br />E Cremation Q Entombment
<br />Q Removal Q Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE t F DEATH (Mtk
<br />June 4,
<br />S. DATE OF BIRTH(Mo.,
<br />June 13, 1988
<br />OTHER 0 Nursing HomeILTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />Sd. COUNTY OF DEATH
<br />Hall
<br />$e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />'Ob. NAME OF. SPOUSE (First, : Middle, Last, Suffix) If wife, give maiden
<br />Valerie Juedes
<br />14a. INFORMANT -NAME
<br />Valerie Palu
<br />18a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Caroftean '< Hunt
<br />16b. LICENSE NO.
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />174r FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, $tate):
<br />All' Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CITY / TOWN
<br />Gibbon
<br />904E522.1E O(T UAIIT$
<br />IW YES Q NO
<br />14b. RELATIONSHIP Tti DEOEDENT
<br />Spouse
<br />tec. DATE (Mo, Day,
<br />June)11, 202.2
<br />13
<br />STATE
<br />Nebraska
<br />CAUSE OF DEATH ISee instructions and examples)
<br />18. PART I. Enter the chain of events- -diseases, 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 on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Respiratory Failure
<br />in death) r DUE TO, ORAS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)Acute Renal Failure on Chronic Kidney Disease
<br />any, leading to the cause listed::.
<br />DUE TO, ORAS A CONSEQUENCE OF:
<br />N0ERLy1Nt cam c) Peripheral Vascular Disease
<br />(dhteeee or injury that initiated
<br />the evens resulting in death) ` DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d) Liver dysfunction
<br />48.'EARTIkoTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death
<br />Pe(rcytOpenla Clostrtdiurn DlfPicile,hospice
<br />40. IF FEMALE:..
<br />Not pmgnaelt:wpldnpastyear
<br />Pregnailt atfitM of death:.
<br />❑ pM9eanE but pr*gnant within 42 days of death
<br />Not pregnant, but pregnalll43 days to 1 year hafoia death
<br />Wtknown if pregnant ithin. the pest year
<br />22a. DATE OF (NJURY{tulo Day, Yr.)
<br />22d. INJURY AT WORK?
<br />YES ;,❑ NO
<br />APPROXIMATE INTERVAL
<br />oneat(0deaUi
<br />Immediate
<br />onset to death
<br />Days
<br />notresulting In theunderlying cause given In PART I.
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident 0 Pending investigation
<br />0 Suic de 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b.IF TRANSPORTATION'INJURY
<br />QDri .00perator
<br />t Paeeanger
<br />❑ Pedestrian
<br />❑ Other, (Specify)
<br />onset to death
<br />Days
<br />19. WAS MEDISAL.EXAMiNER
<br />OR CORONER.. CONTACTED?
<br />❑ YES` \ ® NO
<br />21c. WAS AN AUTOPSY PEREORMEI '?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINtilliKIS AVAILABLE:'
<br />TO COMPLETE CAUSE OP DEATH?
<br />❑YES D..NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />ION OP INJU1IY .STREET 8, NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 4, 2022
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />June 8, 05:00 AM
<br />234:•To lite bast of;sty knowledge, death occurred at the time, date and place
<br />arie due to ree.2.auss(s) stated. (Signature and Tale)
<br />Michael A. Donner, MD
<br />28. DID TOBACCO U$E CONTRIBUTE TO THE DEATH?
<br />❑ YES Ea NO 0 PROBABLY 0 UNKNOWN
<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 />toe. 0n the basis of examination and/or Investigation, to my opkNat Math hccaxieti aE 3
<br />the t(me date and place and due to that ceuse(a)statetl.(Sletuiiaasndcitta)
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES ®NO
<br />27 NAME,1TLE;ANC) AciDRESS OF CERTIFIER (Type or Print
<br />Michael A' Donner; MD, 729 North Custer Avenue, Grand Isia'id, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />►ok-12_17 Bad -nen n C
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a Is NO__,
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 14, 2022
<br />
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