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<br />WHEN JiFII$ °COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA,
<br />GERTYIIES THE DEBELOW TO BB:0-.,4 TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE -:WITH THE NEABRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />:RECORDS..FF/CE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF:ISSUANCE
<br />11/24/2020
<br />LINCOLN, NEBRASKA
<br />20220823
<br />44M
<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. DECEDENTS -NAME . (First, Middle, Last, Suffix)
<br />David Martin Bailey
<br />4:GiTYANDSTATE OR TERRITORY,! OR FOREIGN COUNTRY OF BIRTH
<br />Colfax County, Nebraska
<br />t SOCTAL SECIIRrniNUMBER
<br />80(140.3277
<br />8b, FACILITY•NAME (tf not Institution, give street and number)
<br />Kearney Regional Medical tenter
<br />SCOTTY OR TO . i OF DEATH (Include Zip Code)
<br />'E 5.eamey 68845
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />94. ETREET AND NUMa R
<br />7426 West Abbott Road
<br />9b. COUNTY
<br />Hall
<br />6a. AGE - Last Birthday 5b. U
<br />(Yrs.)
<br />86
<br />2. SEX
<br />Male
<br />NDER 1 YEAR 5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />10e MARITAL STATUS >AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed, 0 Divorced ,❑ Unknown
<br />fATHER'S.NANIE tFlrst,
<br />Glen Bailey
<br />9c. CITY OR TOWN,
<br />Grand Island
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Josephine Ann Pensick
<br />HOUR
<br />MINS.
<br />3. DATE OF DEATtt: dila, Day,;Yr.);
<br />November' TV: •
<br />6. DATE OF 131
<br />March 26, 1934
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other(Sperdfy)
<br />I8d. COUNTY OF DEATH
<br />Buffalo
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />Nosplce 6acllity
<br />9g IN81tlE 0.
<br />is• 13 EVER IN U SARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) N0
<br />15 METHOD OF DISPOSITION
<br />Burial ❑ Donation •
<br />cretnetio } ❑ Enteinbment
<br />}
<br />c R>Nnovat > D Diller (Specify)
<br />12 MOTHER'S -NAME (First,
<br />Ellen: Andersen
<br />14a. INFORMANT -NAME
<br />Josephine Ann Bailey
<br />ISa. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a,: FUNERAL HOME NAME AND MAILING ADDRASS (Street, City or Town, State)
<br />N Faiths Funeral Home, 2929 S. Locust Street, Grand island, Nebraska
<br />16b. LICENSE NO.
<br />1071
<br />Middle,
<br />CITY / TOWN
<br />Gibbon
<br />Maiden
<br />Y LIMITS
<br />NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />ATE (Mo y, Yr)
<br />rember 18, 2020
<br />CAUSE OF DEATH (See instructions and examDIESI
<br />18. PART I. Eller the chain of events -diseases, injuries, or eomplicadons�hat directly caused the death. DO NOT eller terminal events wch as cardiac" arroat
<br />respiratory arrM, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additiaW lines 1 neceseary.
<br />IMMEDIATE CAUSE:
<br />(MMED(al'tE C4)48 n t a) Acute Hypoxic Respiratory Failure, Hypotenstot
<br />Ar east ortenditbs resulting
<br />b
<br />eremite
<br />Sequentially list conditions, if
<br />any, reeding to the cause listed
<br />nifNie a
<br />r tits. UNDEfl(.YiNS.CAUBt
<br />Ielaiiase or injury thea sated
<br />a the events resulting in death)
<br />a LAST
<br />dt ...,
<br />9r
<br />of
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) BR Plural Effusion, Lung Mass,
<br />DUET
<br />c)
<br />OR AS A CONSEQUENCE OF:
<br />STA"t .. .
<br />Nebraska
<br />1Tb Zip Code
<br />6880)::
<br />APPROXIMATE INTERVAL
<br />onset:to
<br />Hous. f
<br />onset to death
<br />Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />, PART II.OTFIER 8K#NIFICANT COI
<br />,abates Mellitus, HTN,
<br />2 r IF FEMALE:;
<br />❑ Nat pregnetlt within Aaetyear
<br />.: ❑ ;PtegnantNtumeofdwoe
<br />italsoorminol,-114Sontint within 4t days of death.
<br />li 0 Not pregnant, but pregnant 43 days to 1 year before death
<br />O Q,: Unknown if pregnant, within the past year
<br />TIONS -Conditions contributing to the deet
<br />g 22d. INJURY AT WORK?
<br />o0
<br />❑ YES ....❑NQ
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident ❑ Pending investigation
<br />❑ Suicide ❑ Could not be determined
<br />King In the underlying cause gWJen in PART 1.
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION
<br />0 Driver/operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />onset to death
<br />'VAS MEDICAL EXAMINER ;'
<br />OR GOROI+ifR CONTACTED?'
<br />]YES ®NO
<br />INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />21d. WERE AUTOPSY ffterINGS AMILASLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO..
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f.';tOCATION:OF INJURY STREETS NUMBER, APT.NO.
<br />tv
<br />23a. GATE OF DEATH (Mo., pay, Yr.)
<br />November 11, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />NOYt31t.ber 13.2020
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />04:07 AM
<br />4
<br />TO the beet or my knowledge, death occurred at the time, date and plan
<br />and thea teem cause(s) stated.; (signature and Title)
<br />Ishrat A. Saif, MD
<br />2
<br />5
<br />STATE
<br />24a DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24e, on the basis of examination andlor InvestlgatlOn, inlay ®Pinion
<br />the time, date and place and due to the cause(,) stated. (Signatl
<br />ZIP GODS ::
<br />OF DEATW
<br />24d. TIME PRONOUNCED DEAD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 2$a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YES ❑ NO : IDPROBABLY ❑ UNKNOWN 13 yes NO
<br />27. NAME, *ri.., AND ADDRESS OF CERTIFIER (Type or Print
<br />. ishrat A. Saff,p10, 816 22nd Ave., Suite 100, Kearney, Nebraska, 68845
<br />8a. REGISTRAR'S SIGNATURE
<br />124-4a-17 8
<br />gtaccunedat
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ID YES'
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 16, 2020
<br />1
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