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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 />DATE L)F ISSUA M E
<br />6/:112{22
<br />LINCOLN, NEBRASKA
<br />oqu.:3(.�)���'��14(�dif lino'�e�i11))Iirlel�,i((Q((i144'o.Y.lo.
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<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 />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME '(First, Middle, Last, Suffix)
<br />Vicki Jean Davison
<br />4, CITYAND.8TATE OR -TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand island, Nebraska
<br />7:8OctAL SECURITY NUMHER
<br />505-74-5158
<br />Se. AGE - Last Birthday
<br />(Yrs.)
<br />68
<br />8b,'FACILITY=NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />8c CITY OR TOWN OF 0 TH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d STREET &kip NUMBER
<br />624 B BiSmark Rd
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />22 07206
<br />3. DATE OF DEATfI;(Mo„ lbay,y,)
<br />March 8,'20.2.2
<br />6. DATE OF BJIHTT1(Mo., Day, Yr.)
<br />DAYS
<br />ea. PLACE OF DEATH
<br />HOS PITA). inpatient
<br />0 ERIOu patient
<br />Q DOA
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />Aupust23.?653
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedents Honor
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />10a: MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />0 Married,: but separated ❑ Widowed 0 Divorced 0 Unknown
<br />11 FATHERENAME (First,
<br />lglchard Thayer
<br />Middle, '-Last,
<br />tOb. NAME OF SPOUSE (First,
<br />Ricky Carl Davison
<br />13. EVER IN U S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk) No
<br />16. METHOD OF DISPOSITION
<br />Burial ❑ Oonption
<br />Crernason ❑ Entombment
<br />l Removal= ❑Other(Spedty)
<br />9f. ZIP CODE
<br />68801
<br />H(I . INSIDE t"i'TY: IM)TS
<br />[ ' YEs }'NO
<br />Middle, Last, Suffix) If wife, give
<br />12. MOTHER'S•NAME (First, Middle,
<br />It Annebe)le Jankovitz
<br />14a. INFORMANT NAME
<br />Ricky Carl Davison
<br />18a. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />Malden Surd
<br />16b. LICENSE NO.
<br />1071
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Cemetery
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town,:.State)
<br />Alt FaRhs Funeral Home 2929 S. Locust Street, Grand Island, Nebraska
<br />14b. RELATIONSHIP'TO'DECEDENT
<br />Spouse
<br />18c. DATE (Silo.; Day Yr:):
<br />March 212
<br />CITY I TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />CAUSE OF DEATH (See instructlons and examples)
<br />18. PART I. Enter the chain *favorite- -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular nbrillation without. showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDLA`rBc 0.0g. a)ASP'RATION
<br />dtSalae or conditlon resbltittp
<br />in death)
<br />Sequentially list conditions, If
<br />any, Needing to the caulisted
<br />on Iinea
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) SEIZURE
<br />onset to death
<br />Minutes
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />Enter the UNDERLYINGCAusE c) Posterior reversible encephalopathy syndrome. (PRES)
<br />(disease or injury that initiated
<br />the events resulting: In
<br />LAST
<br />1 &. PART ii. OTI tEEI SI'
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)West Nile encephalitis (confirmed case):.:
<br />onset etooth
<br />2 Mdkithe
<br />ANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />20. IF FEMALE:!
<br />Not pragnannt wlaprt past year
<br />❑r Pregnant at tenant. items
<br />LJ Not Pregnaid, but psegnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑.,, UMcnown,#:pregnaed within the past year
<br />22e.sDATE OF:(NJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES ,❑NO
<br />21a. MANNER OF DEATH
<br />El Natural ❑ Homleide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />21b, IF TRANSPORTATION INJURY
<br />0 DdueriOperator
<br />Q Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />19, WAS MEDICAL EXAt NEI
<br />OR OORONER CONTACTED?
<br />❑ YES ® NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES [Q NO
<br />22b. TIME OF INJURY
<br />e, DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF 1NJURT' STREET 8 NUMBER, APT.NO.
<br />23a. DATE Of DEATH (Mo., Day, Yr.)
<br />March 8, 2022
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />4: O AM
<br />e bet. ofmy knowledge, death occurred at the time, date and place
<br />due to thqiause(s) stated. (Signature and Title)
<br />Shane J Burr, MD
<br />STATE
<br />IxIP CQDE :i
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />Ortthe basis of examination and/or Investigation. In my opinion dealt
<br />the dine, date and place and due to the causes) stated (signature ftJ
<br />201. 41R TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES ;� NO-PROHABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DQNATION BEEN CONSIDERED?
<br />El YES [ NO
<br />27; NAME, TITLE ANt)ADDRESS OF CERTIFIER (Type or Print
<br />Shane J'urr, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT€3
<br />Not Applicable if 28a is N
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 25, 2022
<br />
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