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<br />�� STATE OF NEBRASKA
<br />f/�t4ti�111ra a.yQtfylillPPP.tii�F
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<br />rKEN THIS COPY CAARIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CEATIPIES THE DOCUMENT BELOW TO
<br />A TKUE COPY ISR THE{fl7IG/NAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND •
<br />MAN $EICV10ES, VITAL. RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATB F1SSfiAN
<br />3/22!2023
<br />iNCOL• , NEBRA*
<br />int
<br />NT'r� NANIII (>Yirst M
<br />Ma. Hughes , '
<br />202.30270
<br />SARAH BOHNENK:4.MP ;r
<br />ASSISTANT STATE REGISI'RA
<br />DEPARTMENT OF HEAL
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Last, Suffix)
<br />STATE Of TERRITORY;_OR:FOREIGN COUNTRY OF BIRTH
<br />DCiAL SEdtIRITY Hill
<br />07 26-84:65
<br />HER
<br />8c OrrY Oft TOWt OF DEAtH
<br />1flieSt PDltt 68788"
<br />tEeu(001DE-ST.0.
<br />ebraska;'.•
<br />9d St8EET4 D NUll BE6
<br />540.E Washington
<br />S
<br />Iud)Zip Code)
<br />9b. COUNTY
<br />Cuming
<br />Sb.'AGE - Laet.Birthday
<br />(Yrs.)
<br />5b. U.NDER 1 YEAR
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH :.
<br />HOSPITAL © •,.'
<br />0 ER/Outpatlent
<br />OF DEATH 0 Married 0 Never Married
<br />fdowed. 0 ,Divorced 0 Unknown
<br />%+#04.04.NAME {Ftihai Middle Last, Suffix)
<br />rankM .Feil lws
<br />13 srfBR iN; u s ARMED FORCES? (dive dates of service if Yes.
<br />(Yes.Noror;4lnit){ tO
<br />9c. CITY OR TOWN
<br />West Point
<br />2. SEX.
<br />Female
<br />3. DATE'Of '40141.40.70*Y
<br />March 17, 2023
<br />6c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />OTHER, 0 Nursing f
<br />0 Decedent'
<br />❑ Other (Spec
<br />I8d. COUNTY OF DEATH?
<br />Cuming
<br />9e. APT. NO.
<br />1ffb. NAME OP SPOUSE (First, Middle, Last,
<br />John N Hughes
<br />9f. ZIP CODE
<br />68788 . .
<br />Suffix) If wIfe;:give'mel
<br />II
<br />112 MOrHER'S•NAME (First, Middle,
<br />Mary:: Ann Featherston
<br />14a. INFORMANT -NAME
<br />Douglas Hughes
<br />EMBALMER -SIGNATURE
<br />Not Embalmed
<br />tEd. CEMETERY, CREMATORY OR OTTER LOCA ON
<br />DouglasTrade Service & Crematory
<br />,,,PUN)*RAL HOMENAME AND' MAILING` ADDRESS (Street, City or Town, State),
<br />tnntck.Fianera(Se ces Inc, 8 0 S. Colfax; West Point Nebrask
<br />CAUSE OF DEATH (See Instruct
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Omaha
<br />Maiden. Su
<br />rig INSIDE DI1 LIM.I`1`S.
<br />I. YES [ NO
<br />14b. RELATIORHi1> TODECEIiN'CJ
<br />SOS
<br />ns and examples)
<br />'r.the chainctf events diseases; Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />;,,or ventricular fffidgation-without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines if nae
<br />tMMEDIATE.:CAUSE:
<br />"a) Respiratory. Failure
<br />et death)
<br />$sggentlety list COildil
<br />aity;;leadih9 t4ta>: call
<br />on: ine a,::::.:.:>:.
<br />the
<br />e'er
<br />'DUE TO; GRAS A CONSEQUENCE OF:
<br />Neurologic decline
<br />TO;.QR ASA CONSEQUENCE OF:
<br />E vIMeI A[ i
<br />N that Initial.
<br />in lath)
<br />Seta
<br />E. TO, OR AS A CONSEQUENCE OF:
<br />MART ii cmEIt S
<br />Tr9nti It1fE
<br />I(TICANT CONDITIONS -Conditions contributing to the death but nat re/tatting/0 the: nderiying cause given in PART
<br />'1a1l0es-Melittus Type 2
<br />a' zDAT!
<br />li
<br />21a. MANNER OF DEATH •
<br />Ea Natural 0 Hori lade
<br />0 Accident d Pending Investigation
<br />0 Suicide El Could not be determined
<br />2215. TIME OF INJURY
<br />21n, IF TRANSPORTATION INJURY
<br />0 DriverfOperator
<br />)0 Passenger
<br />0 Pedestrian
<br />El Other (Specify)
<br />21c. WAS ANA))
<br />MED?
<br />21d..WEREAUTOp3Y FDINet PALA
<br />TO COMPLETE CAtlsE x)61 DEATH?:
<br />ta,:NOs
<br />22c PLACE OF INJURY Athomefarm, street, factory, office building constiul
<br />IBE HOW INJURY OCCURRED
<br />NUMBER, APT.NO.
<br />1•4.A..:.1:0:f DEATH No., pair, Yr.)
<br />March 17, 2023
<br />CITY/TOWN
<br />23b, DATESIG.NED (Mo ,Day Yr.). 23c. TIME OF DEATH
<br />ar t 2Q>202 08:31 PM
<br />30 '%G #iieb9S(af mi; knotaleil`ge,'death occurred at the time, date and place
<br />•atfd tiva to lii,d:.Cdtiea($i stated. (aignatureand Title)
<br />25.1343 *.•
<br />AGG6 USE.t"ONTRIBUTE _TO.THE DEATH?
<br />NO j] PROBABLY . ❑ UNKNOWN
<br />Tlt'I«EAN0,4. ORtSS OR CEOTIFIER (Type or Print
<br />F ertae Ile er UO 500'E Decatur St, West Point, Nebraska, 68788"
<br />a. REGISTRAi
<br />EE
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />.24c.. PRONOUNCED DEAD (Mo., Day; Yr.)
<br />24b. TIME.
<br />DEATH
<br />Q4e On the basis of examination andior inveatigetior, hf my.ophl(an.daa
<br />fhe f(me, date and place and due to the cause(sl stated (Siignatiire:
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES IMO
<br />4.4}7 glift/Leolk4.41.-Lf›-
<br />26b. WAS CONSENT.
<br />Not Applicable if 26a (s
<br />butted lit
<br />YEs Qr
<br />28b. DATE FILED BY REGISTRAR (Mow thy, 'Yr.)
<br />March 21; 2023
<br />
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