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<br />STATE OF NEBRASKA
<br />WHEN IS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, ir 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 />.111111111=1•11.
<br />PAM. OF ISSUAN.CE
<br />3/31/2023
<br />LINCOLN, NEBRASKA
<br />202?.O1830.
<br />3#44-11
<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 />DEREQEN7144A94515yett, Middle, - Last, Suffix)
<br />[Dna Marle vans
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (ortti., powyr.)::
<br />March 18, 2023.•
<br />6. DATE OF BIRTeflfeo.,1344,...ye,)
<br />4. CITY'AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />SOCIALSEQUOITTNOMEIER
<br />•••••••••:' ":' •••• •
<br />505-900757
<br />Eak,AGE - Leapt Birthday itb. UNDER 1 YEAR
<br />(Y/e.)
<br />61
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />CHI Health5t. Francis HMS
<br />g8c CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />1
<br />1
<br />FATeee*N.Amel(frs.,.. Middle, 'Lett, Suffix)
<br />▪ . .
<br />• ,,..„
<br />Robert vans
<br />• •• • •
<br />MOS.
<br />DAYS
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />August 24..1961
<br />8a. PLACE OF DEATH
<br />HOSPITAL E Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Face*
<br />0 5/4/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specie")
<br />18d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9b. COUNTY
<br />Hall
<br />9d. STREET ANIXNUMBER:::•.
<br />84:8 V.V,LOUte:•Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />IWINESBE crrexpirre::
<br />l71 Never
<br />. :
<br />OF DEATH 0 Marrieds
<br />.77a- Divorced c]
<br />0 Widowed
<br />Married Out separated 0 marr ' ^ Unknown
<br />Marrled
<br />r
<br />1
<br />1.
<br />13. mete U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />•10W NAME OF SPOUSE (F11,3t,''' Middle, Last,
<br />12. 411OTHEirt.kNAME (First,
<br />Doris Hartman
<br />14a. INFORMANT -NAME
<br />Kathy Evans
<br />Suffix) If wife, give maiden name
<br />Middle, Malden Sumame)
<br />14b. RELATIONSHIP To DEMENT
<br />Sister
<br />16. METHOD OF DISP0SITIOQaurtat nN
<br />[if 6.,;4.iiiit3.:setopiPenent
<br />0lii4ie4(•:;i10Otliet (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Alt Faiths Funeral Home, 2929 S. Locust Street Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />19. PART I. Enter the chain of events- 411sesses, Injuries, or complicadons-that directly caused the death. DO NOT enter terminal events such as cardiac wrest,
<br />respiratory arrest. or ventricular fibrillation without shoed.; the etiology. DO NOT ARBRFVIATE. Enter only one cause on line. Add 0001110051 11001 If necessary.
<br />IMMEDIATE CAUSE:
<br />• a) Acute Hypoxic Respiratory Failure
<br />dr".etiliteiMerideltine.]'W
<br />, ••
<br />10461" DUE TO, OR AS A CONSEQUENCE OF:
<br />SequtistIally list cOttditiOns, o b)Multifocal Pneumonia and Severe Sepsis
<br />any, leading to the saute listed
<br />111100 DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the. uNDEREVIND OUSE C)
<br />(dus„„„ or irgurytbat Initiated
<br />the SWIMS resulting in death)
<br />LAST DUE TO, OR AS A CONSEQUENCEd)
<br />OF:
<br />16c. DATE (Mo., Day, Yr.)
<br />March 22:.20.23:
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />enset:/04e4l44.4.i?
<br />Days
<br />18.•14/g4TNOTHER.SPIVIMANT CONDITIONS-ConditIons contributing to the death but notresteting tif thoiederiying cause given In PARTI..
<br />Mai'metabolic encephalopathy
<br />20. IF FEMALE: '..
<br />DU Net ere/lev/e eleen Par
<br />poignant at Akna (oakum
<br />NO Pfellitiret but Mageant within 42 days 00 0.0111
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0
<br />Unknown ecstasies own the past year
<br />21a. MANNER OF DEATII,
<br />Natural 0 Non*I
<br />o AccideM Pending Investigation d
<br />Other (Specify)
<br />0 Suicide 0 Could not be determine
<br />22a. DATE of 11,1JuRY (mt>., DaY, Yr.)
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 .theier/Operator
<br />0Pittlestrren
<br />0
<br />onset *Beath
<br />onset to death
<br />19 WAS MED1AL EXAMINERk
<br />ORocRoNwpo
<br />OV
<br />ES E N0
<br />21c. WAS AN AUTOPSY PRfOR1!,c47
<br />DYES
<br />21d. WERE AUTOPSY FINDINGS AWOLA
<br />TO COMPLETE CAUSE Of DEATH?
<br />DYES 0 NO
<br />22c. PLACE OF INjURYAt Knme,'fitnnietreet factory, office building, construction site, 0(0. (Spec(
<br />22d. INJURY AT WORK?
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />DYES 0 NO
<br />anotiO00060, STREET & NUMBER, APT.NO.
<br />niOcA:.
<br />CITY/TOWN
<br />2 • •••:' 23a. DATE OF DEATH (Mo., Day, Yr.)
<br />S
<br />,
<br />March 18, 2023
<br />23b. DATE SIGNED (Mo., Day,
<br />Yr.) 23c. TIME OF DEATH
<br />l
<br />. i:i •':•. ttlarthil,;::,20230918 PM
<br />2 .i.. ...4 tzroueb,,,.risi nitstiuseknorloodtagt,daeath occurred at the time, date and place
<br />Suresh Manapuram, MD
<br />0. .... .. .... ...i.....1!! . s . (Signature and Title)
<br />STATE ZP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEI
<br />lee 70the11eme of examination ancifor investiga ion, M my opinion cletiPtIree rrad;
<br />11Mtline. data and place and due to Inc cause(s) stated. (Signature 401)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES NO ........:0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />OYES El NO
<br />. :27. HAme,.:TiTLE AND ADDREsS OF CERTIFIER (Type or Print
<br />Suresh Manapurarn, MD, 2620 W Faidley Ave, Grand Island.:Nebraska; 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO YES 0 NO 4"•.!
<br />Ul 11 olD
<br />28b. DATE FILED BY REGISTRAR (Mo.,,I3ay;,
<br />March 2a:,-.2023'
<br />
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