|
11tt0 10,11
<br />1 / 5 11 / 1
<br />1 I \ / a 1 I i ".� � � 1 11 � 1
<br />0 a t 1 i 11 1 � \ 01 11 Z
<br />I s \ 11 S \5 0 I a f ,� 11 11 i 1 i
<br />/ 5 1 rc 11111 r1 c , n 0111 e, 1 S r Z
<br />i I r1 ,1, ( i ,r i� �. 11 (e6esSu t lYa ,t,)uui int Vm�ie>41a 1 iI$.�li YoSac.ale,,,,,,r i ,r a
<br />r�lA�E9?& Err(,1,,0�1.14u dR)� P u _r.. �G1C11>?ya 11
<br />0'11114;
<br />.1L
<br /><..__..______ _STATE OF NEBRASKA
<br />r,
<br />/rhfu'Cc\
<br />82tfhit(111ttta-. ,rrryynrd
<br />400/JJ1ry
<br />3tt ,CJ
<br />SI
<br />)7)qua
<br />iir,"
<br />takVI01» WO,�111 QUAL Srrt,)i))l')
<br />t(I!'u,1ny������pyyp�,1ya ��ha::utMCCCi))
<br />1: IllsQtrl/�AI�rA)U?x elf
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OP ISSUANCE
<br />12/27/2022
<br />LINCOLN, NEBRASKA:'
<br />302760
<br />SARAH BOHNENIAMI
<br />ASSISTANT STATE REGISTRA
<br />DEPARTMENT OF HEALT
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIRCATE OF: DEATH
<br />1. DECEDENTSNAME {Rust, Middle, Last, Suffix)
<br />Linda Sue Peters
<br />4. CITY AND STATE OR':TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />San Antonio, Texas
<br />7. SOCIAL SECURITY NUMBER
<br />507-82,2442
<br />8b. FACILITY -NAME t)
<br />CHI Health St. Francis
<br />5& AGE • Last Birthday
<br />(Yrs.)
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />8a. PLAG. QF DE 4TH
<br />H SiPNrA(, Q Inpssolit
<br />® ER/Outpatient
<br />Q DOA
<br />DAYS
<br />HOURS
<br />MINS.
<br />22 17442
<br />3. DATE OF DERPI o., Day Yr.}'..
<br />December 1ti, 2022
<br />August 16,
<br />OTHER 0 Noosing Hofl$I(.T
<br />❑ Decedent's Home
<br />o Other (Specify)
<br />Ba CITY OR TOWN Of:DEATH (Include Zip Code)
<br />Grand 1sIartd 88803 •
<br />9a. RESIDENCE -STATE
<br />Nebraska .
<br />8ti..s3reser.ANC1 NUMSBR
<br />8:18 W.12th Street
<br />I3d. COUNTY OF DEATH
<br />Hall
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separ
<br />11. FATHER'S•AME (Fti
<br />MaNln J Gonna s
<br />Widowed 0 Divorced 0 Unknown
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />91. ZIP CODE
<br />68801
<br />to fatdiity
<br />so emiDE OOY LIMITS:
<br />® v
<br />MOO
<br />100: NAME OF SPOUSE (Fltst, Middle, Last, Suffix) If wife, give maiden titan
<br />Craig Peters
<br />13 Et7EFt #N U.S ARMED FORCsert Give dates of service if Yes.
<br />(Yes, No, or Unk.) NO
<br />15. METHOD OF: DISPOSITION
<br />l l Burial Doonsion
<br />❑:; QrematI0n Q Entombment
<br />Q Rrnnoval 'Q ether (Specify)
<br />14a. INFORMANT -NAME
<br />Craig Peters
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12. MOTHER'SNAME (First,
<br />Alice < Robinson
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />1Ta.,FUNERAL:I OME NAHIE AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Punerat Home, 2929 S. Locust Street, Grand Island, ,Nebraskta
<br />Maiden Si
<br />18b. LICENSE NO.
<br />CITY / TOWN
<br />Grand Island
<br />14b. RELATIQNSHIP TO DECEDENT
<br />Spouse
<br />18c. DATE (Mils, Day, Yr)
<br />D 15, 2022:
<br />TATEC
<br />Nebraska
<br />CAUSE OF DEATH (S instruct)bns and examples)
<br />1e. PARTE Enter the chain Of atlonta• -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricularfibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines H necessary.
<br />9dtA p1ATE rrAUt Pl+e
<br />disMse or candAie. teen
<br />Sequentially list conditions, if
<br />::::sm..lees hog ta vie:causee fseo
<br />on dna a .
<br />Enterde UNDER .ING*AUSE
<br />(tliseess of in)u/ythet inkhorn..:
<br />the events resulting M del
<br />LAST
<br />18.
<br />IMMEDIATE CAUSE:
<br />a) cardiopulmonary failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) diabetes
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) obesity
<br />RTA. OTHER S
<br />E TO, OR AS A CONSEQUENCE OF:
<br />onset to death
<br />Ii<ICANT CONDITIONS -Conditions contributing to thedeeth bwt:notraw
<br />30. IF:FEMALE
<br />® Not pregnereeiutra ps leader
<br />© Pregnant dame of death
<br />0 Nd•pregnant;: but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant49 days to 1 year before death
<br />Unknown B P[egnaravdihin the past year
<br />2a. DATE OF INJURY (MO., Day, Yr.)
<br />22d. INJURY AT WOI
<br />DYES 0N(I;
<br />..... ..........................:..
<br />......................................
<br />22e.
<br />21a. MANNER OF :DEATH
<br />Natural 0 Homicide
<br />o Accident 0 Pending Investlgetlon
<br />❑ Suicide 0 Could not be determined
<br />the underlying cause given In PART I.
<br />22b. TIME OF INJURY
<br />22c. PLACE
<br />SCRIBE HOW INJURY OCCURRED
<br />22f. t CATION OF INJURY:' STREET & NUMBER, APT.NO.
<br />t
<br />E
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 10, 2022
<br />21b. IF TRANSPORTATION INJURY
<br />❑y
<br />�DrW6' /Operator
<br />u passenger
<br />© Pedestrian.
<br />o Other (Specify)
<br />19. WAS S,
<br />OR •alf#NER CONTACTED$
<br />❑ NO
<br />21c. WAS AN AUTOPSY PERFORMED?.
<br />❑YES fa NO
<br />21d. WERE AUTOPSY FINDINGS AVAIIABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES 0 N ...
<br />F INJURY.At home,;farm, street, factory, office building, construction
<br />CITY/TOWN;:;
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Ds9ember 19.2022 10:35 PM
<br />22d. To the bait itf my knowledge, death occurred at the time, date and place
<br />and due to the sause(s) stated. (Signature and Title)
<br />Theresa E Tassey, MD
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, In my op kdtm death occurred Jit
<br />the time, date and place and due to the causes) stated. (Signature sittt.'ftile) . .
<br />25. DID TOBAACQO USECONTRIBUTE TO THE DEATH? 26e. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />Q YES Q NQ Q PROBABLY ® UNKNOWN ❑ YES NO
<br />i1 NAME,' ITLEAND ADDRESS OF CERTIFIER (Type or Print
<br />Theresa I ITassey,'MD, 2820 W Faidley Ave, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE ]
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a is NO-< :; Q vas ❑ NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />.... .......
<br />December 19, 2022
<br />
|