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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE • STATE OF NEBRASKA, IT
<br />CERTIFIES. THE DOCUMENT BELOW TO BE .A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />10/14/2021
<br />LINCOLN, NEBRASKA
<br />5
<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 />1.:IpECIEDENTSAANEJEIrst, Middle, Last, Suffix)
<br />Terrance.>James.€ Cook
<br />CERTIFICATE OF DEATH
<br />4: CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCtAL SECURITY NUMBER
<br />46 7.7799
<br />fib FACILITY -NAME (If not institution,; give street and number)
<br />Bryan Medical Center West
<br />8c G(TY OR TCNN OF•DEATH (Include Zip Code)
<br />Lincoln 68502
<br />9a. RESIDENCE -STA'
<br />Nebraska
<br />9d; STREET AND NUMBER
<br />1615 N Huston Avenue
<br />9b. COUNTY
<br />Hall
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />65
<br />5b: UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER TRAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 1EInpatient
<br />❑ ER/Ou patient
<br />0 DOA
<br />10a. MARITAI: STATUSAT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced -❑ Unknown
<br />11, FATHER'S'NAME tFirst, Middle, Last, Suffix)
<br />Paul James CodiC
<br />13, EVER IN U.S'i ARMED FORCES?
<br />(Yes, No, or Unk.) NO
<br />15..METHOD OFDISPOSITION
<br />Burial ❑ Donation
<br />.,. Cremation ❑ Entombment
<br />0:Rernoval ❑ 001er (Specify)
<br />Give dates of service if Yes.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (MMAo. _D -*Yr.)
<br />October 1, 2021
<br />6. DATE OF BIRTH (Mo.,'DayYr.)
<br />January 28, 1956
<br />OTHER Nursing Home/LTC 0 Hospice Facility
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Lancaster
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />fig INBDEGITYUMTTS'
<br />AYES QNO>'
<br />AOb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden nine
<br />Pamela Rose :Stevenson
<br />12. MOTHERS -NAME (First, Middle, Maiden Surname)
<br />Darlene Delores Fitzsimons
<br />14a. INFORMANT.NAME
<br />Pamela Rose Cook
<br />I6a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />1Ta, FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Al)
<br />PEith.t Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska::
<br />16b. LICENSE NO.
<br />CITY I TOWN
<br />Gibbon
<br />14b. RELATIONSHIP TODECEDENT
<br />Spouse
<br />16c. ATE (No., Day,Yr.j
<br />Octobers 2021.0:'
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART I. Enter the chain of events- 4iseases, 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 />EDIATE CAUSE Fliiii1
<br />aseeraof4)flpn eeliitg.
<br />indtathi
<br />Sequentially list conditions, if
<br />any leading to the cause:llated
<br />Enter the UNDER VING CAUSE
<br />•
<br />(disease or Injurythatinitiated
<br />the events resulting in death)
<br />LAST
<br />IMMEDIATE CAUSE:
<br />a) COVID-19 pneumonia
<br />STA'T`E
<br />Nebraska
<br />.47b. Z(p.Cretle:
<br />68$01;
<br />APPROXIMATE INTERVAL
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />blAcute hypoxic respiratory failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Mantle cell lymphoma
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)Acute on chronic systolic congestive heart failure
<br />t,.. onset to death
<br />10 Days
<br />`onse*t0 de
<br />2 Monti't8`
<br />onset to death
<br />1 Month
<br />15 PART 8 OTH.ER SIGNIFICANT CONDITIONS -Conditions contributing triiha,OeathhUt noties0lting:in the underlying cause given In PART I.
<br />Adteial inSu ficiemcy+, acute pulmonary embolism, deep venous thrombosis, disseminated histoplasmosis, hypothyroidism,
<br />Acute kidney Injury
<br />,20 IF FEMALE ..
<br />0 NdtpregnartE..`.wlthlnpast.yeer
<br />pregnant et tininbrdeam
<br />Ot pregnaaf; but gtagnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown lf pregnant within the past year
<br />a.
<br />INJURY (Mo, Day, Yr.)
<br />g 22d. INJURY AT WORK?
<br />❑YES 0 N
<br />t3
<br />T .
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ©Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ other/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />WAS` MEAIiCALE$AMINER
<br />R CORONER CONTACTED? `:
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES r NO
<br />21d. WERE° AUTOPSYFINDINGSAVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO.._
<br />22c. PLACE OF INJURY At home, farm, street, factory, office building, construction site
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />.00ATION.;OFINJURY.. STREET &NUMBER, APT.NO..
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 1; 2021
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />OctODET 4, 2021
<br />23c. TIME OF DEATH
<br />07.14 PM
<br />l5d C4:lite best of rtay knowledge, death occurred at the time, date and place
<br />end tote cause(s) stated (Signature and Title)
<br />Abhilash T. Kolli, MD
<br />25..DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES ; ) NO TO PROBABLY, 0 UNKNOWN
<br />STATE
<br />24a DATE SIGNED (Mo., Day, Yr.)
<br />-
<br />.5'S
<br />k 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />ZIP CODE
<br />54e. An the basis of examination and/or hi resttgatlon, In m y ephden des0.eaaurret at
<br />the time, date and place and due to Mia camels) stated.`(stgneturnandpie) 3 '
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES � NO
<br />26b. WAS CONSENT GRANTED?:::
<br />Not Applicable if 26a Is NO ❑ YES : ❑ N
<br />21. NAME, Trite AND ADDRESS OF CERTIFIER (Type or Print
<br />Abhilash T. Kohl, MD, 2300 S 16th, Lincoln, Nebraska, 68502
<br />28a, REGISTRAR'S SIGNATURE+)
<br />28b. DATE FILED BY REGISTRAR (Mo.,
<br />October 7, 2021
<br />(, Yr.)
<br />MA
<br />
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