|
'.1
<br />\ a
<br />41) 33., lit++rr rir'f[llti
<br />{
<br />tl
<br />s \
<br />5
<br />r
<br />1
<br />t r\ \ 111
<br />n,1i+ r \t
<br />11.„;lt, ft1\ 1.. ,,t1n•
<br />\+1 / \ / r 1 \ \ 11 \
<br />T/s I \ / -\11 11/ 1 //. 1
<br />/ \ 11 I / \ 11111 - \ \1 I / \ (11111 J .
<br />/ 1111) J i I 1 / r. t
<br />IIII�Jg;ruli+0,4y, �auu,idle.rrlrrea�tz,��\1,111tU,hl.1/6...,uAeuB\\atatu„e,M✓.y.t. �a�at..lAti(l.r/,e,r 1M,1a\.Itu,+ItJ.r,1�,r,�Mltr:y\�i1,INJ
<br />r,l in ( 11
<br />STATE OF NEBRASKA
<br />ntA!0))/, Nu tr
<br />e � ..nits+iPPPtt� x.74/1111111111`.: nrr tttl
<br />+//ll.€1111u
<br />rrrrr,lllt ...... �!74411111N1i\'�
<br />&i'll4'illh
<br />ulllll
<br />IVO
<br />WHEN TINS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERWCES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OFISSUAN E
<br />•LINCOLN, NOE112400.,
<br />NUMMI*
<br />1. DECEDENVS4NA N.'{):Mret, Middle, Last, Suffix)
<br />€uric' Sindt
<br />4. CITE* AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />202304354
<br />bra,
<br />SARAH BOHNENICAMP
<br />ASSISTANT STATE REGISTRA
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES:
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Oscolaz Nebraska •
<br />7. SOCIAL SECU RiI1r NU ER
<br />147 2497
<br />FACILITYNA
<br />CHI Health St. Frsi
<br />Sc:GITtOpt ToWN.•
<br />OPDR
<br />Grand islt(Td
<br />6880,
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d..STREETAN0 Num R..
<br />1oa MAR TAI.. TAT
<br />0 Married, but a
<br />1 PATIIER'S hi
<br />Robert '.I
<br />tion, g)ve street and number)
<br />(Include Zip Code)
<br />9b. COUNTY
<br />Hall
<br />AT TIME OF DEATH ® Married 0 Never Married
<br />Widowed 0 Divorced 0 Unknown
<br />13 `txyi;> #N US ARMED tC
<br />(Yes, No, or Unk.) No
<br />Middle, Last, Suffix)
<br />POSI7iON
<br />Latton
<br />Entombment
<br />Ottier(Specify)
<br />ye dates of service If Yes.
<br />5e. AGE - Last Eirthday:
<br />(Yrs.)
<br />5b . UNDER 1 YEAR
<br />MOS.
<br />8s PLI4CE OFOEATH
<br />HOSP rA4 'inpatient OTHER 0 Nursing
<br />©
<br />ER/0u patient 0 Decedent's
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand. Island
<br />0 Other (Specify)
<br />ISd. COUNTY OFIDEATH
<br />Hall
<br />Be. APT. NO.
<br />10b. NAME'OF SPOUSE (first, Middle,
<br />Jerald Sundt
<br />12 MOTHERS44AME (first, Middle, Malian,
<br />N(�llie Ccx
<br />14a. INFORMANT -NAME
<br />Jerald Sindt
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />91. ZIP CODE
<br />68801
<br />Suffix) if wife, give
<br />tin
<br />led. CEMETERY, CREMATORY OR Omen LOCATION
<br />Grand Island City Cemetery
<br />Vs. FUNERAL. HOME NAME ANEMAILING ADDRESS (Street, /City or Town, State)
<br />AD Faiths Fanerai Home, 2929 S. Locust Street Grand Island,;<Nebraske
<br />18b. LICENSE NO.
<br />CITY I TOWN
<br />Grand Island
<br />, CAUSE OF DEATRISeOJnstrt t€ones and examoles)
<br />it. PART!. smertliw anion or events - -diseases, injuries, or sompxationathet directly caused the death. DO NOT enter terminal events such as cardiac street,
<br />mapiretary arrest, sr vsmrlsulsr fibrillation without 'sowing the etiology. DO NOT ABBREVIATE. Enter only one cause on ■ one. Add additional Enos If need
<br />IMMEDIATE CAUSE:
<br />a) severe sepsis
<br />do*. 0000001**
<br />rase/
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially Est eendlsons, 8 b)
<br />any, leading to thecau*a:.h
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />:the UNi 37NQ0*U58' C)
<br />(asaarenr hquryfliatrauiatea
<br />the wsnts re' gin deotii) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />1 �
<br />NDIT64S.Conditlons contributing to the death but not reeultin
<br />sus, acute on chronic liver failure, each/axi
<br />L.PARTd1 OTHHI RStGNtl.)C
<br />i'etasteic breast cancer;
<br />..2O. iF IEMALE ;
<br />®:;Nat nragnraH:wdhln year
<br />:40
<br />Q "tllnt ppgaIM, bmpnppni nt within 42 days of death
<br />Q Not pregnant, but pregnant 43 days to 1 year before death
<br />Ynllno mN.:RrestarntaNthtntile past year
<br />2234'DATE G R iN4U :tMtl < lay, Yr.)
<br />220. INJURY ATWORK?
<br />: OYES ::.ErN6:
<br />e
<br />t3CAISON'CIf:
<br />21a. MANNER OF DEATH
<br />® Natural © Homicide..:
<br />0 Accident 0 RAMO rg Investge hep
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. Pt A EDP INJURY he
<br />SCRIBE HOW INJURY OCCURRED
<br />& NUMBER, APT.NO. CITY/TOWN':'
<br />23a. DATE OP DEATH (Mo., Day, Yr.)
<br />May 9, 2022
<br />Gb DATE I NED (Mo., Dal, Yr.)
<br />June 10 2022
<br />23o. TIME OF DEATH
<br />01.05 AM
<br />t
<br />lad.. Utile easter royIns ledge, death occurred at the time, date and place
<br />foil ohne trrt#�e aitse(s)
<br />stated. (Signature and Tinel
<br />Zeeshan KHatid, MD
<br />islth
<br />Ing cause given In PART I.
<br />21b, IF TRANSPORTATION INJURY
<br />a tifiOrroperator
<br />QPassenger
<br />Pedestrian
<br />0 Other (Specify)
<br />sea.
<br />21c. WAS AN
<br />0 YES
<br />21d. WERE AUTMPAYP1rlaBlllgB'AV
<br />TO COMPLETE Goa OPQIATH?
<br />0 YES
<br />STATE
<br />24a DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />S
<br />a
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YSS NO �IPROBABLY ®UNKNOWN
<br />2� I 'tTrL AA TI A ROMP beiterifilktrype or)rint
<br />ZeitiiiiiriiiditifidND, 2620 W Faldley Ave, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28a. HAS ORGAN OR
<br />O YES
<br />Via. �i r�1?k
<br />24b. TIME
<br />241-
<br />240. the theiMilige of examination andlor srveaagaaen, ie
<br />Ste:tTme'date and place and due taliteeaaa(e)
<br />TISSUE DONATION BEEN CONSIDERED?
<br />(NO
<br />Sib. W
<br />Not Applloable If
<br />28b. DATE FILED BY RBGIB4 use we, asy.
<br />June 13, 2022
<br />
|