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<br />fa'�'Cttt,aa5 rtSTATE OF NEBRASKA _-
<br />x t 117111 htf`h
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT. 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 />DATE OF ISSUAhfCE
<br />9/43/202x. 2
<br />LINCOLN, NEBRASKA
<br />20220.8 x'44
<br />24} &f:41,47
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />TATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1 DECEbENTSd4AME (first, M
<br />Alan Eugene .Weinrich
<br />Eddie,
<br />st, Suffix)
<br />4. City AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />> SOCIAL SECURITSt NUMBER
<br />606.60-87p
<br />' 8b. FACILITY.NAME (If not Institution, give street and number)
<br />a::. CHI Health St. Francis
<br />to
<br />ac. CITY OR TOWN [)1r DEATH (include Zip Code)
<br />€3rand Island 68803
<br />9a. RESIDENCE -STATE
<br />, Nebraska
<br />d.:$TREET AND NUMBER
<br />4716 W Guenther 90
<br />9b. COUNTY
<br />Hall
<br />sa. AGE - Last Birth
<br />(Yrs.)
<br />68
<br />los MARITAL STATUS AT TIME OF DEATH ® Married :❑ Never Married
<br />0 Married, but separated t] Widowed ' ❑ Divorced 0 Unknown
<br />11 FATHER S -NAME (First,
<br />Eugene G Weinn:0
<br />Last, ' Suffix)
<br />10. 'EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />• :; (Yes, No, or Unit) NiO
<br />u 15. METHOD OF DISPOSITION
<br />Bdrfal ❑OOrtation
<br />'C
<br />cremadop DEntombment
<br />[QRemoval::❑Other(Specify)
<br />ty
<br />:6b::UiDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE O! DEATH
<br />HOSPfTA(. E inpatient
<br />ER/Ou patient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEA'I'tt {Mrj
<br />July 12, 2022
<br />2 12027
<br />3aY Yt;i;'
<br />6. DATE OF BIRTH (Mt., Day,Yr:
<br />April 17, 1
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9s. APT. NO.
<br />(if. ZIP CODE
<br />68803
<br />Ai
<br />19b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give til
<br />Judith A Sperling
<br />14a. INFORMANT -NAME
<br />Judith A Weinrich
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12, MOTHER'S -NAME (First,
<br />Clarice A Hawkins
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FQNERAL )TOME NAMEAND MAI,UNG ADDRESS (Street, City or Town, State)
<br />Apfel Furtaral l'forrre, 1123 UU. 2nd, .Grand Island, Nebraska
<br />18. PARt I. Enter the chalk of
<br />respiratory sweat. or venLllular
<br />IMMED1AtECAUSE(Final:
<br />dtgaee or tAnR*tdit reaa&a
<br />in death}
<br />Sequentially list conditions, If
<br />any, lesding.to tha'9auee.heted ..
<br />on taxi
<br />DUE TO, OR AS A CONSEQUENCE OF: •
<br />Enter';helaND811;f.YtNOCAt H ,c)severe chronic obstructive lung disease
<br />(dlsaaae w hgutyithat 1141bated
<br />tab. UCENSE NO.
<br />Middle,
<br />CITY / TOWN
<br />Gibbon
<br />Maiden-Surfsi
<br />14b. RELATIONSHIP TOOECEEiEbW
<br />Spouse , -'
<br />18c. DATE (Mo. Day, yr.) ,
<br />July 13, 202^2
<br />•
<br />Nebraska
<br />CAUSE OF DEATH (See lnstructiots arid examples)
<br />Injuries, or complications -that directly caused the death: DO NOT enter terminal events such as cardiac arrest,.
<br />Minion without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />EDIATE CAUSE:
<br />acute on chronic respiratory failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)STAPHYLOCOCCUS aureus pneumonia
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />/AL'
<br />to
<br />Days
<br />onaetto.aoath
<br />Years
<br />i onset to death
<br />18 .PART II OTHERS! GNIfiCANT COND1TIONS.Conditions contributing to the death but not reatdting(n the underlying cause given In PART I.
<br />Atrial filbrlltllfl©n Ci .:.. ifc diaptolic'rongnstive heart failure
<br />20. IF FEMALE;
<br />Nat pregnant within pasty:,
<br />Pregnantat time of death.;
<br />[:j Notprognbrfk, but pregnant within 42
<br />:Not pregnant, but pregnant 43 days to 1 ye
<br />Unknown if regnant within the past year
<br />19,,
<br />2a, DATE OF INJURY (MC., Day, Yr.)
<br />22d. INJURY At WORK?
<br />33 .❑ YES :❑ NQ.
<br />before death
<br />21a. MANNER OF DEATH
<br />Natural ❑ Hom)clee
<br />❑ Accident ❑pending investigation •
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 PassengerEl
<br />22c. PLACE OF INJURY At home,:;.
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJUR4? STREET 8, NUMBER, APT.NO.
<br />23a. DATE OP DEATH (Mo., Day, Yr.)
<br />July 12, 2022
<br />23b. DATE SIGNED (Mo., Ga'
<br />Sete ibe 2.20
<br />$d T?',xha best pf ti p icngwI
<br />and due 10 tits Cause()) ati
<br />Jay G..Anderson, h
<br />a,
<br />cITY/TOW1.
<br />23c. TIME OF DEATH
<br />11:33 AM
<br />nh occurred at the time, date and place
<br />Signature -and Title)
<br />21c. WAS A
<br />❑ YE
<br />E:1
<br />Pedestrian 21d. WERE AUTOPSY FtN'DiEltds•AVAit;;ABi:E:
<br />Other (Specify) TO COMPLETE CAUSE OF DEATH?
<br />❑ YES 0-J10..
<br />farm Street, factory, office building, construction she, elf€, (E
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH..
<br />Zap. TIMI
<br />2Ae. Ad the beats of examination and/or Inveatiga Ion, Infiy 9
<br />1111 titile,'date and place and due to the cauaeis) stated.)
<br />25. DID TOBACCO USE CONTRIBUTE TO. THE DEATH?
<br />YES ❑ NO 0 PROBABLY 0 UNKNOWN
<br />27. NAME, Tfll,E aNijADOESS OF CERTIFIER (Type or Print
<br />ay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska,8803
<br />28a. REGISTRAR'S SIGNATURE',
<br />28a. HAS ORGAN OR SSUE DO
<br />DYES El NO
<br />ATION BEEN CONSIDERED?
<br />28b. WAS CONSENT
<br />Not Applicable If 28a is NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Driiy, Yr.)
<br />September 6, 2022
<br />446.
<br />
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