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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OP THE ORIGINAL RECORD ON FILE WIT, TILE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OP ISSUANCE
<br />....... .......................
<br />..................... ....
<br />3/27/2023'
<br />LINCOLN, NEBRASKA
<br />1. DECEDENT$ NAME (Firat,
<br />frena (II Elie Steele
<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 />Middle, Last, Suffix)
<br />4. CITY AND STATEORTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />I
<br />Nebraska City, Nebraska
<br />SOCIAL SECURITY NUMBER
<br />505 50-91:08
<br />Sb. FACILITY -NAME Of not Institution, give street and. number)
<br />CHI Health St, Francis
<br />8o CITY OR TOWN OF DEATH (I
<br />::Gratitf Island 88803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d,.STREET AND NUMBER
<br />4246 W Airport Rd! !
<br />Jude Zip Code)
<br />54 AGE - Last Birthday
<br />(Yrs.)
<br />80
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />9a. PLACE OF D ;ATH
<br />HOSPJTAL ®Inpatient
<br />❑ ER/Outpatient
<br />DOA
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />lad.
<br />HOURS
<br />MINS.
<br />3. DATE OF 05*..TH (Mo%, Dsy, Yr.);';
<br />March 242023
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />November 19.1942 . ..
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (specify)
<br />COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />1O MARITAL. STATU$ AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />9f. ZIP CODE
<br />68803
<br />r'.
<br />9p lasiosCITY 1MCr$'
<br />❑YES NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name
<br />Don Lavon Steele
<br />1/ :FATHER'S LAME :(Hirst, : .Middle,
<br />John George Peterson
<br />Last,
<br />12 MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Stella Irene Briley
<br />13: EVER IN U.S ARMB > FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Don Lavon Steele
<br />1
<br />15. METHOD OF DISPOSITION
<br />} Burial d Donation
<br />Crefnation ❑ Entombment
<br />Removal : Gather (Spec,
<br />Qfy)
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />16b. LICENSE NO.
<br />1495
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Alt Faiths Funeral Home, 2929 S. Locust Street, Grand Island,' Nebraska
<br />CITY / TOWN
<br />Grand Island
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />98c.. DATE (Mo , Day, Yr.}
<br />March 29, 2023
<br />STATE
<br />Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />13. PART I. Enter the chain of events- diseases, 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 one line. Add additional Tina If necessary.
<br />IMMEDIATE CAUSE:
<br />a) acute hypoxic respiratory failure
<br />IMMEDIA#ECAustr(FIII T
<br />disease or oondition resvl8np
<br />In dptlt) ...
<br />Sequentially Est konditions, If
<br />zany,. leading to the caua,llsted
<br />on'lide a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Pulmonary embolism
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNOEftLYINGCAME c) Malignancy
<br />(diseeae er tnjuryyThat initetdd
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />97b. Zlp Code::;
<br />88801>
<br />APPROXIMATE INTERVAL
<br />onset to deatit
<br />1 Day ..
<br />onset to death
<br />5 Days
<br />onset fo death
<br />4 Years
<br />18, PART II, OTHER SIONIICANT CONDITIONS -Conditions contributing to the death but not resulting In Bre underlying cause given in PART I.
<br />Breastcancer, lung cancer, E. coil sepsis, brain mass, stroke, Comfort:cares,acute'raspiratoryfailure
<br />20.,IF;FEMALE:..
<br />❑ iNotpregnhntwlthlnpdetyear
<br />❑ Prepnaht u Dine of deelh }
<br />❑ Not pre9Mnt, but prepmnt within 42 days of death
<br />❑:: Not pregnent, but pregneM 43 days to:1 year before death
<br />[� Unknown If pregnant within the part year
<br />ATE OF INJURY (Ma Day, Yr.)
<br />22d. INJURY AT WORK )
<br />D YES ONO
<br />2•51a. MANNER OF DEATH
<br />Naturals ©Hom?cide
<br />❑ Accidem ❑ Pending Mvestigetien
<br />❑ SWc de ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />,.,0 Driver/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />Ea YES ❑ NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES' Q NO .
<br />22c. PLACE OF INJURY At home, farm, street, factory, office building, construction ske, etc {may)
<br />22E ocAt'ioN OF INJURY'; STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 22, 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />March 23 2023
<br />bat of my knowledge, death occurred at the time, date and place
<br />eand Title)
<br />~ 1 Srikanth Reddy Kothapalli, MD
<br />CITY/TOWN`
<br />23c. TIME OF DEATH
<br />10.23 PM
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />�IPCODE k
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. OA the balls of examination and/or investigation, In my opinion dotal eCPurred at
<br />the time, date and place and due tothe cause(s) stated. (Signature and 71tle)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES El No 0 PROBABLY ® UNKNOWN
<br />/27, NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Srikanth Reddy Kothapaili, MD, 2620 W Faidley Ave, Grand .Island, Nebraska, 68803
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />28a. REGISTRAR'S SIGNATURE
<br />26b WAS CONSENT GRANTED?
<br />Not Applicable If 28a Is NO 0 YES
<br />❑ NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 24, 2023
<br />
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