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<br />WREN WISP COPY CARRIES THE RAISED SEAL • OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE.A TRIPE 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 01:ISSUAI
<br />12/10/202
<br />LINCOLN, NEER
<br />Amended
<br />:
<br />SARAH BOIINENKAMP
<br />ASSISTANT STATE REGISTF
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />�1 CECEDENT'8•NAMff (first, Middle, Last, Suffix)
<br />Roger W tsOtt Roscoe
<br />CERTIFICATE OF DEATH
<br />4. CITYAND ,STATE R TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Central City, Nebraska
<br />7 SODA( SEURIT'f NUMBER
<br />55.08-38 0382
<br />8b. FACILITY44AME(if ricCinstituti
<br />CHI.Heal#h St, Francis
<br />, give street and number)
<br />8e CITY OR TOWN QF DEATH (Inctude Zip Code)
<br />Grand Island 613803
<br />I9a. RESIDENCE -STATE
<br />i Nebraska
<br />++ 90:1:,iSTREET AND NUNBER
<br />3;114 Vilest 15th Sheet
<br />3
<br />$.
<br />0
<br />9b. COUNTY
<br />Hall
<br />5a.AGE - LditBlrthday
<br />(Yrs.)
<br />79
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL ®'Inpatient OTHER 0 Nursing Home/LTC
<br />❑ ER/Outpatient 0 Decedent's Horne
<br />DOA 0 Other (Specify)
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo, briscW )
<br />November 24, 202)
<br />6. DATE OF'BIRTH (Mo., Day; Yr.)
<br />February 27 /9.41;
<br />10a, MARITAL STATUS AT TIME OF DEATH ® Mauled 0 Never Married
<br />0 Married, but separated [ Widowed 0 Divorced 0 Unknown
<br />Middle,
<br />Suffix)
<br />t00100.0::.i$.6
<br />1 LEVER IN U 5. ARMEo FORCES? Give dates of service If Yes.
<br />(Yes, No, or link.) Yes 10/23/1959-06/23/1963
<br />16. ME.THOD:OF DISPOSITION
<br />Bw1eI ❑ Donation
<br />Crematreut ❑ Entombment
<br />Remove(" ❑Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />Ice Faculty
<br />8g. JNSIDikt`ITY I~INIi#$;
<br />SAE,05.!YES.I
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Rosalie Mae Homfeld
<br />6 11 :FATHER $ ;NAME t!rst. Lest,
<br />Alfred
<br />12. ROTHER'S-NAME (First,
<br />Clara Wilson
<br />14a. INFORMANT -NAME
<br />Rosalie Mae Roscoe
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />115, FUNERAI..HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Ali Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (S
<br />16b. UCENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16e. DATE (Mo., Day, Yr,)
<br />November 28; 2020
<br />instructions and examples)
<br />S 18. PART I. Enter the chain of events- •diseases, injuries,' or complIcations•that directly caused the death. DO NOT enter terminal events such ascardiac arrest,
<br />E3 respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines 1 necessary.
<br />1 IMMEDIATE CAUSE:
<br />;p]!diIP7E01A1'E CA3i8E {Final
<br />4ieease or.eondicibn reaugins=
<br />in death)
<br />Sequentially gat conditions, If
<br />any,.tea„ding to.the cause:{istad
<br />oif1ne a. ..
<br />Enter tree UNDERLYING CAUSE
<br />O I (disease or Injury that initiated'.
<br />�) Acute Hypoxic Respiratory Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Acute Respiratory Distress Syndrome
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) COVID 19 Pneumonia
<br />UE TO, OR AS A CONSEQUENCE OF:
<br />.STATE
<br />Nebraska
<br />1Tb Zip Code
<br />6$l30'Pi `:
<br />APPROXIMATE INTERVAL
<br />to death
<br />18. PART{I OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but net resulting in the underlying cause given in PART I.
<br />Septic Shock, Staphylococeeus Aureus BaCteremia, Paroxysmal Atrial Fibrillation, Hypertension, Hyperlipidemia,
<br />Thrombocytopenia, Acute Kidney Injury
<br />onset to death
<br />19. WAS MEDtCAI EXAMINER
<br />QR CORtJNER CONTACTED?'
<br />® YES ❑ NO
<br />0tryF.� JL;;
<br />FEMAE.
<br />L-1 Notprsensrdvrip,-RIHrs
<br />oPregerudatBmaofdeaki`
<br />0 Not pregnant, but pregnant wkhin 42 days of death
<br />4t 0Not pregnant, but pregnant43 days to 1 year before death
<br />:. SO13• 0 Unknown kpregnantvdthln the past pear.
<br />20.ikbAltatINJURY (Ma, Day, Yr.)
<br />21a. MANNER OF DEATH
<br />® NaWreI 0 HdngCide
<br />Accident © Pending fevestigotfon
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />210.. IF TRANSPORTATION INJURY
<br />0 Oliver/Operator
<br />© Passenger
<br />0 Pedestrian
<br />Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES Ea- NO.
<br />21d. WERE AUTOPSY FINDINGS AVAN ABI E
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES D No
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site,
<br />ESCRieE HOW INJURY OCCURRED
<br />'t4 22d. INJURY ATr-WORK?. D
<br />0 YES
<br />22f:LOCATION OF INJURY STREET 5, NUMBER, APT.NO.
<br />et
<br />W ]
<br />S o
<br />e
<br />224,
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 24, 2020
<br />And
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />NDvernb024, 2020
<br />23e. TIME OF DEATH
<br />03:20 AM
<br />Md Tod* beet Om
<br />Y knowledge, death occurred et are time, date and place
<br />and due td the cause(s) stated. (Signature and Title)
<br />Zeeshan Khalid, MD
<br />ONTRIBUTE TO THE DEATH?
<br />{PROBABLY El UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD::. ..
<br />244,].:011 the basis of examination and/or Investigation, in my opinion dretii p}xurratt et
<br />the tone, date and place anddue to the cause(s) stated. (Slgnaturo anti Tkle) ` ..
<br />25. 010 TOBACCO USE G , 26a. HAS QRGAN:OR TISSUE DONATION aEEN CONSIDERED?
<br />YFS ] NO ❑ YES • Q NO
<br />27 NAME,'nTla AND Ab1,RESS OF CERTIFIER (Type or Print
<br />Zeeshan Khalid, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />1 24 n.en ot-sLe.-
<br />Amended
<br />12/10/2020 Item '7'-508-28-0382 To 508-38-0382
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is 18'
<br />YEs' LJ N
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 30, 2020
<br />0`
<br />
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