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<br />WHEN mis COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, tr CERTIFIES THE DOCUMENT BELOW TO
<br />BE A 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 />r7y4ltll)BfIPPdt�� rrrrrn,r�„ > '
<br />1.zece ENT..'.S NAME::(First,
<br />Date Alen Martin
<br />Middl
<br />202206991
<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 />est,
<br />Suffix)
<br />4 CITY ANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Spirit Lake, Iowa
<br />1 SOCIAl. S RITYNUMBER
<br />48418-6088
<br />AGE - t-ast 8lrthday
<br />(Yrs.)
<br />8b. iFACILITY-NAME (If not Institution, give street and number)
<br />CHI, Healttt,S . Francis
<br />8C. ny OR TG WN (IF DEATH (Include Zip Code)
<br />Grand Island 6(ti.903
<br />9a RESIDENcte-r TE
<br />1 Nebraska
<br />Cd;S`('REETAND NUMBER
<br />4133 Praiile Ridcge Lane
<br />1
<br />9b. COUNTY
<br />Hall
<br />8b. UNDER 1 YEAR
<br />2. SEX
<br />Mate
<br />8c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />aa. PLACE OF DEATH
<br />HOSPITAL® Inpatdent
<br />❑ ER/Outpatient
<br />❑ DOA
<br />iIa MARITAL:&TAWS AT TIME OF DEATH I `Married ❑ Never Married
<br />crated 0 Widowed ❑ Divorced ❑ Unknown
<br />11 FATHER S4IAMa (First,
<br />3heron > Mattln
<br />Middle, Last, Suffix)
<br />13 ,EVER IN 11 ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unit.) Yes 01/18/1978-01/31/1998
<br />15. METHOD OF DISPOSITION
<br />0 Burial ❑1ionation
<br />Cremation ❑Entombment
<br />8 IQ Removal ; . Q Outer (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (PHO Da1r,Y#
<br />February 1.,:2022
<br />C. DATE OF BIRTh (Mo., Day, Yr.)
<br />July 3, 1960
<br />OTHER 0 Nursing Home/LTC
<br />Decedent's Home
<br />❑, Other(Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />1
<br />lob. NAME OF SPOUSE(First, Middle, Last, Suffix) If wife, give`,;
<br />Tina Maron
<br />14a. INFORMANT4IIAME
<br />Tina Martin
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />1$d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />lie. FUNERALMOME NAME AND MA UNG ADDRESS (Street, City or Town Staff),
<br />tpfet Futietat! Hottie, 1123 W. 2nd, Grand Island. Nebraska
<br />12. MOTHER'S -NAME (First,
<br />Shirley Kohler
<br />n
<br />ItOtte. teieTS."
<br />I I
<br />16b. LICENSE NO.
<br />Middle, Maiden Surname)
<br />CITY / TOWN
<br />Gibbon
<br />14b. RELATIONSHIP r0 DECEDENT
<br />Wife
<br />lac. DATE ((Nit Day, Yr.
<br />Februartr 2,:202 .,;
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events- -diseases, Nudes, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory onset, or ventricular fibrdlatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMIt1aDV1' MCAUSE(mnel a) acute hypoxic respiratory failure
<br />omen or Fonde'lon resuiting ' : .
<br />Int ,1011
<br />Sequentially S,
<br />any, leading to the taupe hated
<br />'3
<br />mer Aha UNDER..LY9Ir3 G111f9S
<br />Idleeeati'orInju ythat pidated
<br />1&PART II OirHIEI $
<br />obesity, 4labetes
<br />,28 IF FEMI
<br />0 Not.pregnarRwlBiir€peel yesr
<br />0 1.„5",tetlirhaofdee#t r
<br />i❑ NH Pregnant, but prognant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown if.,prognald wRMn the past year
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)adult respiratory distress syndrome
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)COVID 19 pneumonia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />IFICANT CON
<br />IONS=Conditions contributing to the death
<br />22d. INJURY AT WORK?
<br />❑ YES ...:❑ NO
<br />21a. MANNER OF DEATH
<br />▪ Natural ❑ Homladde
<br />o Accident ❑ Pen:ding Investigation
<br />0 Suicide 0 Could not be determined
<br />cat not resulting In the underlying cause given In PAR
<br />22b. TIME OF, INJURY
<br />21B.IF TRANSPORTATION
<br />❑ Dnvor/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />❑ Other. (Specify)
<br />INJURY
<br />49. WAS MEDICAL EXAMINER .[
<br />ORCOfiONERc t4TACTED?
<br />Ii3 YES 0 M
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSYkkONOS AVAiLABLII
<br />TO COMPLETE CAUSE OP DEATH?
<br />❑ YES [ NO.
<br />22c PLACE OF INJURY At home, farm, Street, factory, office buildin
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f :LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF ".DEATH (Mo., Day, Yr.)
<br />February 1, 2022
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />t`ek�r}�artr:7.2022 "' 03:11 PM
<br />2Sd Ta:the fleet of my knowledge, death occurred at the time, date and place
<br />and due to the Sause(s) stated. (Signature and Title)
<br />Zeeshan Khalid, MD
<br />28. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 Yds i,,Z1 NO PROBABLY ®UNKNOWN
<br />27NAME, TITI, AND AD D RESS OF CERTIFIER (Type or Print
<br />Zshart Khalid, MD, 2620W Faidley Ave, Grand Island, Nebraska, 68803
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />.24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24e On the basis of examination and/or Investigation, in my opInlnn death tiled q t
<br />the time,. date and place and due to the meets) stated. (Signature atdl e)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED OE
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES NO
<br />1285. REGISTRARS SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO n YES
<br />triko
<br />28b. DATE FILED BY REGISTRAR (Mo., Day;
<br />February 7, 2022
<br />
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