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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 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 />............. ....... ................
<br />...... ...... ......................... .
<br />...... .............. .................
<br />DATEOFISSIIANCE
<br />11/212021
<br />LINCOLN, NEBRA,
<br />•
<br />w
<br />a
<br />202305047
<br />t � /50411.41.44.. _.
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRA
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />1. DECEDENT!S.NAME (Ftlit, Middle, Last, Suffix)
<br />Eugene Biton Jacobson
<br />CERTIFICATE OF DEATH
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Wolbach, Nebraska
<br />T. SOCIAL SECURITY NUMBER
<br />507-24-5 65
<br />Sa AGE • Last Birthday.
<br />(Yrs•)
<br />97
<br />8b. FACILITY -NAME (f,not InetltuNon, give street and number)
<br />CHI Health St Francis`
<br />in. cm OR TOWN OF DEA
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d.<STREET AND NUMBER
<br />.:2826 Bre iNvood BI Id
<br />b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a, PLACE OFDEATH
<br />HOSPITAL Ea inpatient
<br />❑ ERIOu patient
<br />0 DOA
<br />(Include Zip Code)
<br />9b. COUNTY
<br />Hall
<br />10a..MAR1TAL.STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />Married, but separated Q Widowed 0 Divorced 0 Unknown
<br />itFATKER1-NAME
<br />George Ja,
<br />9c. CITY OR TOWN
<br />Grand. Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DE,.!1 {Mo., Day Yr ).
<br />October 21.,.2021 ..... .
<br />6, DATE OF BIRTIf(Mo.,
<br />Septembe(°13,
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. nljetoksf Ypart5
<br />Traii-St01: (1):110':''T!
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden tie
<br />Wilma Rauert
<br />13.'EVER IN 11.S. ARMED FORGES? Give dates of service if Yes.
<br />(Yes, No, or Unit.) Yes ! 03/03/1944-04/11 /1946
<br />18. METHOD OF DISPOSITION
<br />Buhl []Donation
<br />O CrematIo[ti Entorrittment
<br />D aemovai ❑ oN1er(Specify)
<br />EOTHER'$A• ME
<br />AIiGe ; (First,
<br />Pedersen 12 M
<br />14a. INFORMANT -NAME
<br />Wilma Jacobson
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a ,FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town State)
<br />Alt Faiths FOneral l'3ome, 2929 S. Locust Street, Grand Island, :Nebraska
<br />18. PART I. Enter the Chain ofsvant
<br />respiratory arrest, or ventriiul
<br />a
<br />IMNtE HATE CAUSE
<br />disease or rendition resuaing <
<br />In death}
<br />Sequentially list conditions, if
<br />any,Nading to the eause fisted
<br />on ane a
<br />Entad the UNDEI I.WINO'Catit ES
<br />(diseaed or Injury: hat initiated.:
<br />the events resulting
<br />LAST
<br />M
<br />16b. LICENSE NO.
<br />1495
<br />Middle,
<br />CITY I TOWN
<br />Grand Island
<br />Malden Sum'
<br />14b. RELA2tONSl#P'To CtECE0EN7
<br />Spouse
<br />16c. DATE (Ma,, Daax:Yr) ;; :::
<br />October 27 2021
<br />STATE ;
<br />Nebraska
<br />CAUSE OF DEATH (See Irtstructioi
<br />and examples)
<br />-diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Zine. Add additional linea H necessary.
<br />IMMEDIATE CAUSE:
<br />a) cardiac arrest
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)ventricular fibrillation
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />0) ischemic cardiomyopathy
<br />UE TO, OR AS A CONSEQUENCE OF:
<br />113,..,PART II OTHER SIGNIFICANT: CONDITIONS -Conditions contributing to the death but not resulting 1044 Onderlying cause given In PART I.
<br />hyperO atcen le, Acttte kidney injury, chronic kidney disease, hypertension, congestive heart failure, prostate cancer,
<br />hyperlipidemia, chronic obstructive pulmonary disease,
<br />20. IF. FEMALE;.;
<br />❑ Not pregnant within
<br />I ',pregMpd *Mee O deem::
<br />❑ Not pregnant; but pregrrem within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />::. ❑.. Unknown If pregnant within the past year
<br />t22a, DATE OF INJURY(
<br />d1
<br />c
<br />0
<br />22d. INJURY AT WO
<br />©YES 0
<br />:41)sy, Yr.)
<br />21a. MANNER OF DEATH
<br />Ea Natural 0 Homibide
<br />0 Accident 0 Pending lnvestigalton
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />o Other (Specify)
<br />I S. WAS MEI):ICAL EXAMiNSR:.
<br />OR fI t:ONTACTED%
<br />® YES ❑ NO
<br />21c. WAS AN AUTOPSX PERFORMED:?
<br />❑ YES 10:446-,M:
<br />21d. WERE AUTOPSY FINDINGS AVA(LABL
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YE8 Ono
<br />22c. Pi.ACE OF INJURY,At home, farm, street, factory, office building, construction ell
<br />ESCRIBE HOW INJURY OCCURRED
<br />�22f. LOCATION'OF INJURY STREET 8, NUMBER, APT.NO.
<br />i1
<br />i d. Tb the bed of my Bnowtedge, death occurred at the time, date and place
<br />and due tathe baase(s) stated ('• gnat. _and Title.
<br />Zeeshan Khalid, MD
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 21 2021
<br />Is
<br />CITYITOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />October 22 2021
<br />23c. TIME OF DEATH
<br />07:06 AM
<br />A11
<br />i a 3.
<br />H
<br />o ww 24e. tin the base of examination and/or investigation, in my opinion dead ...s._ 5Rat
<br />the time, date and place and due to the cause(s) stated. (S and 111(b)
<br />s
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />P GQDE.<
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED
<br />2S. DI.D TQBAG:GO� USE CNTRIBUTE'TO THE DEATH?
<br />0 YES ti,,.t NO ,PROBABLY ® UNKNOWN
<br />27 NAME* TITLE AND ADbifESs OF CERTIFIER (Type or Print
<br />Zeeshan Khaild, Mb, 2620 W Faidley Ave, Grand Island, Nebraska',68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES gi NO
<br />28b. WAS CONSENT Gl
<br />Not Applicable If 26a Is N
<br />0 NO:
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />October 28, 2021
<br />
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