|
voms
<br />..:Kitt.........
<br />WINO/T(atSk��}iai)1titia$i wads�ax�)!BA'ltIPtES�6alPihvvlaSa,,,,ib[[fGravi�l��111111Y1i%�l►$3iatinli@lal,w�()alrf
<br />(.._ STATE OF NEBRASKA
<br />w[[rtg[Wpaaa 414IlhilylltfD?�a r a
<br />wwtitlljyilrfttlSal a[rrrrpmn,
<br />r, 'Y�Y)1���i�i�(II/ rl„
<br />,r�� )))1�°.d, (C(((MG ,rna3
<br />((ct,,,, T
<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 />DATE OFISSUANCE
<br />......................................
<br />....... ........ ........................
<br />/9/2023
<br />LINCOLN, NEBRASKA
<br />202305240
<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 />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Donald lay Amick
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Cullman, Alabama
<br />7. SOCIALSECURiTY NUMBER
<br />4:1'9 60»2332
<br />Sb. FACILITY+NAME (If not institution, give street and number)
<br />CHI Health; St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand island 68803'
<br />9a. RESIDENCE -STATE
<br />Nebraska .
<br />9d. 8TREETANI NUMBER:;.
<br />607 Linden:Ave
<br />9b. COUNTY
<br />Hall
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />76
<br />6b. UNDER 1 YEAR
<br />10a.'MARITAL STATUSAT TIME OF DEATH au Married 0 Never Married
<br />❑Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHERS -NAME (First, Middle, Last, Suffix)
<br />Ht)llls
<br />Arbick45
<br />13. EVER IN H S ARMED>FORCES? Give dates of service If Yes.
<br />(Yes, NO, Or Ink.) Yes 10/23/1964-04/22/1969
<br />15. METHOD OF' DISPOSITION
<br />❑'aurfal ❑ DonatlOn
<br />® Cremation;; ]Entombment
<br />❑ Removal ❑ Other(Specify)
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 1 Inpatient
<br />❑'ER/Ou patient
<br />❑ DOA:.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />23 027
<br />3. DATE OF DEAT#1(MO , Day, Yr)
<br />February 27„.x{23
<br />8. DATE OF BIRTH (Mo., Day,. Yr.)
<br />May 31, 1946
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (SpedN)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />So. APT. NO.
<br />9f, ZIP CODE
<br />68801
<br />ice Facility
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Esther Mae Burrus
<br />12 MOTHER'S.NAME (First, Middle,
<br />Dorothy Mildred Basenberq
<br />14a. INFORMANT -NAME
<br />Ba. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />Esther Mae Amick
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />CIN / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />Malden Surname)
<br />18. PART I. Enter the chant 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 on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />tMIaEDtATE#LUSEIPinhI ; a) acute encephalopathy with advanced dementia
<br />disease or condition resuiong
<br />Sequentially list conditions, H
<br />any, leading to the cause fisted
<br />Enter the UNDERt.YINO CAUSE''
<br />(disease or injury -!list inidale8
<br />the events resulting in death)
<br />LAST
<br />18. PARTS OTHER SI
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, ORAS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />$Ii7E CITY tll'AITS
<br />YES ❑ NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse ..0
<br />18c. DATE(Mo, Day, •Yr.)
<br />March 1; 2023
<br />BYATE
<br />Nebraska
<br />tib. Zip;Code .:
<br />68801`.
<br />APPROXI TE
<br />onset fa t
<br />Days
<br />onset t death
<br />IFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART L
<br />20t,-ItFFEMAL.E:
<br />El Nstpre5nailtwltititPpsNyear
<br />[� Fregnard at Bete of Beeth
<br />❑ Not pregnant but pregnant within 42. days of death
<br />❑ Not pregnant but pregnant 43 days to 1 year before death
<br />..❑ Unknown ifpregnaMvdthin the past year
<br />22a, DATE OF INJURYDay, Yr.)
<br />22d. INJURY WORK?
<br />❑YES .[NO
<br />21s. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident ❑ Peatsng Investigation
<br />0 suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b.IF TRANSPORTATION INJURY
<br />cDriv4tlOperator
<br />4.l-{ po onper
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />19. WAS meow-. EXAMINER
<br />OR CORONEaCONTACTEO4
<br />❑ YES' ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES Ea NQ
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE. CIF INJURY At home, fart, street factory, office building, construction site, etc Opacity)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. CATION OF INJURY:. STREET & NUMBER, APT.NO.
<br />a
<br />0
<br />23a DATE OF DEATH (Mo., Day, Yr.)
<br />February 27, 2023
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />March 2 2023
<br />23c. TIME OF DEATH
<br />06:24 PM
<br />23d To the hest Of my knowledge, death occurred atthe time, date and place
<br />and due to the•causes) stated. (Signature and Title)
<br />•
<br />TheWut Yee, MD
<br />et
<br />1
<br />B
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24a. On the b*$ a of examination and/or investigation, in my opinion death dadttffed a.(
<br />the tidie,:date and place end due to the cause(*) stated. (Signetr$8 el(S,'I,ttti)
<br />28a. HAS ORGAN OR TISSU��EEy DONATION BEEN CONSIDERED?
<br />❑YES Ea NO
<br />28. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES u NO J'PROBABLY ® UNKNOWN
<br />2'/. NAME,Ti7LE AND ADDRESS OF CERTIFIER (Type or Print
<br />TFelNut Yee, MD 2620 W FaidieyAve, Grand Island, Nebraska, 68803
<br />28a. REGISTI
<br />R'S SIGNATURE
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑ YES El
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 2, 2023
<br />
|