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<br />OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASK4, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA 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 />DATE Off ISSUANCE
<br />9/23!2022
<br />LINCOLN, NEBRASKA
<br />2022073bet
<br />SARAH BOHNENKAMP f
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />1 pace BNTS4AME {Fi€st, Mtddta, :.. Last, Suffix)
<br />Rosalene ' Josephine
<br />CERTIFICATE OF DEATH
<br />�4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Cedar. Rapids, Nebraska
<br />7 SE pALsecuRITY:NUMSER'
<br />506288660
<br />5a. ABE - Last Birthday
<br />(Yrs.)
<br />a
<br />'t7
<br />1
<br />Sb. FACILITY -NAME Of riot institution, give street and number)
<br />;:; CHI Health St Francis
<br />Sc. CITY OR TOWN of DEATH (include tip Code)
<br />Grand Island 88803
<br />Se. RESIDENCE -STATE
<br />Nebraska
<br />0SREETANI'YNUMBE9.
<br />X47 Oak Street
<br />94 <;
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />ER/Ou patient
<br />0 DOA
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />oa."MARITAL $TATUBAT'fIME OF DEATH .0 Married ; 0 Never Married
<br />0 Married, but separated ] Widowed 0 Divorced 0 Unknown
<br />E 11 FATHiR8dfAME (Fitat,
<br />baiter Olson
<br />Middle, Last,
<br />Suffix)
<br />13. EVER IN U * ARMED:FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) NO
<br />0
<br />Y 15. METHODOF DISPOSITION
<br />' JBurial °tj Donaflon
<br />(] Crampon C] I»nigMbrnem
<br />❑ 12emoval CI Other (Specify)
<br />lob: NAME OF SPOUSE (Float,
<br />Forrest Huffman
<br />HOURS
<br />MINS.
<br />3. DATE
<br />Septi
<br />`DEA'I'H1MMyr Yr,)
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. 2IP CODE
<br />68801
<br />e Fai l*yi
<br />Middle, Last, Suffix) If wife,
<br />t LIMITS
<br />( NO
<br />12. MOTHER'S•NAME (First, Middle, Maiden Sumi
<br />Esther Alden
<br />14a. INFORMANT -NAME
<br />Richard Ray Huffman
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />11a. FUNERAL_ HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2829 S. Locust Street, Grand Island, Nebraska.
<br />. PART I. Enter the chain Of events.
<br />respiratory arrest, Or ventricui
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />14b. RELATIONsH#P' TMS t GEDBNT
<br />Son
<br />18c. DATE (M4, Day;Yr.)
<br />September'14x:2
<br />CAUSE OF DEATH (See Instructions and examples)
<br />compitcations.that-directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />owing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />MEDIATE CAUSE:
<br />a)Severe protein calorie malnutrition
<br />In Steal.,
<br />• DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b) advanced dementia
<br />any, leading to the gi uea SaNifl
<br />en hilae
<br />DUE TO OR A CONSEQUENCE OF:
<br />EntsrtltouNDJERIYINGCAU$E' c)
<br />(dketies.erlrtiurytltaatnEkrard
<br />Lie events resulting in death)
<br />LAST
<br />&PART 1I OTHER StONIPI
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />T CONDITIONS -Conditions contributing to the death but not
<br />tg lathe underlying cause given in PART I.
<br />9IFfEMALE
<br />Not pregnant wi hin pest year
<br />P!rsgnantatt(in9 eath ; ;
<br />.Pio# pregnaed+ but pregnem wit in 42 days ofdeath
<br />0 Not pregnant, but pregnant 4a days to year before death
<br />..<.0 Unknownifpregnatdsdthinthepastyear
<br />.tt 22a. DATE OF INJURY iMO.., Day, Yr.)
<br />g 22d. INJURY AT WORK?
<br />❑YES 0 N
<br />21a. MANNER OF DEATH
<br />El Natural ❑ lHOmic(de
<br />❑ Accident 0 pending Invat<tigeti4tn
<br />0 suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />210. IF TRANSPORTATION INJURY
<br />0 Dever/Operator
<br />pamenger
<br />pedestrian
<br />0 Other (Specify)
<br />21c. WAS Al'
<br />❑ YEA
<br />21d. WERE AU YF
<br />TO COMPLETE CAt
<br />❑ YES
<br />22c. PLACE OF INJURY=At hottirte, farm, street, factory, office building, construction
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />S. 122f LOCATION OF INJURY: STREET 5, NUMBER, APT.NO.
<br />M
<br />ci
<br />23e. DATE OF DEATH (Mo., Day, Yr.)
<br />September 13, 2022;
<br />23b. DATE SIGNER(Mo., Day,
<br />Sab);eilller1.9, 2022
<br />cilia troat ofir..:)0.0er
<br />aiM this Nt il4f O uue(s) e
<br />Srikanth Reddv Kithap
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />07:30 AM
<br />Occurred at the time; date and place
<br />nature and Title)
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />GS AVAILAI
<br />frDEATH?
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />. On the bards of examination and/or Investigation, in:
<br />the time, date and place and due to the cause(e) eta
<br />24b. TIME OF
<br />24d. TIME
<br />EA
<br />25, DID TOBACG,D USE CONTRIBUTE TO THE DEATH?
<br />L YES Q NO 0 PROBABLY ® UNKNOWN
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES I I NO
<br />2?. NAME fl :ANDADDRESS OFCERTIFIER (Type or Print
<br />Sfikanth Reddy Kothapalii, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />1
<br />26b. WAS CONSENT tANTE',
<br />• Not Applicable if 26a is NO
<br />28a. REGISTRAR'S SIGNATURE
<br />et -n 8,444-ix..en
<br />28b. DATE FILED BY REGISTRAR (Mo Day, Yr.)
<br />September 21, 2022'
<br />
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