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<br />STATE OF NEBRASKA
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<br />THIS COPY CARR/ES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA 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 />enmesh
<br />DATE OF ISSUANCE
<br />10/3/20231
<br />LINCOLN, NEBRASKA
<br />202305478
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
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<br />WHEN
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1;t}EECEDENTS NAME;(First, Middle, Last, Suffix)
<br />dames <F'edrick< Blath ' AKA Sam Blath
<br />4;G4 TY AND.STATEON.TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Middlesex, New Jersey
<br />7. SOCIAL SECURITY NUMBER
<br />147-40.4607
<br />5a. AGE -Last; Birthday
<br />(Yrs.)
<br />8b.'FACtLITY.NAME(If not institution, give street and number)
<br />CHI Health St. Francis
<br />Sc.tC)7Y 0R 'QWN OP:DEATH (Include Zip Code)
<br />Graltd island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9tL':STREETIAND NUMBER.
<br />201 SaidiSt
<br />9b. COUNTY
<br />Hall
<br />75;,.
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a PLACE OF DEATH
<br />HOSPITAL E inpatient
<br />ER/Outpatlent
<br />❑ DOA
<br />10s. MARITAL' STATUS' AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced 0 Unknown
<br />11.;FATHER'S44AME (First, Middle, Last Suffix)
<br />Martin ... Blatt) :Sr
<br />11, EVER IN U S ARMED FORCES? Give dates of service if Yes.
<br />(Yee, No, or unit) Yes 05/29/1972-05/29/1974
<br />18. METHOD OF DISPOSITION
<br />I B3urial [ Donation
<br />Cremation ❑ Entombment
<br />Removal: Omer (Specify)'
<br />9e. CITY OR TOWN
<br />Cairo
<br />HOURS
<br />MINS.
<br />2313036
<br />3. DATE OF DEATH; (Mo , pay, Yr.)
<br />September II, 2023
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />OTHER 0 Nursing Home/LTC
<br />❑=Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68824
<br />90INSIDE CiTY LIMITS
<br />SI YES i<'NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden nate;`
<br />Debra Blath
<br />14a. INFORMANT -NAME
<br />Debra Blath
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />1Z MOTHER'S -NAME (First,
<br />Maria . laniero
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Crematory
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, Stats)
<br />LIvinoston.SOrldermann Funeral Home, 601 N. Webb RoSd, Grand Island
<br />Nab
<br />16b. UCENSE NO.
<br />asks
<br />CAUSE OF DEATH (See:instructions
<br />Middle,
<br />CITY/TOWN
<br />Grand Island
<br />nd examples)
<br />13. PART I. Enter the chain of events- -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventdcuiar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) cardiac arrest
<br />Maiden Surname)
<br />INNEDba76 CALOIE
<br />dleeen oteonditionrgsultif'
<br />in iothl
<br />Sequentially list conditions, if b) arrhythmia.
<br />any, leading to Er cause listed
<br />an hire a
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />Stter the UNOE lL.wNG CAUSE Ol, .
<br />(dltvees or druid that Initiiited ,.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />14b. RELATIONSHIP TO.I
<br />Spouse
<br />ECEDI-
<br />16c.' DATE (Mo., Day, Yr.)
<br />September 22; 2023
<br />11L>PART 11 0TtIER SIGNIFICANT CONDITIONS-ConditIons contributing to the death but not resulting in the underlying cause given In PART I.
<br />20.:IF FEMALE,;,
<br />Toopre
<br />t gnant within,past year
<br />PreWtant at thne of deetlt
<br />Not pregnant, bnt pregnant within 42 days of death
<br />Not pregnant, but pregnant 43 days to 1 year before death
<br />�] Unknown! prepaid"within the past year
<br />22* DATE OF INJURY (M4„ Day, Yr.)
<br />22d. INJURY AT WORK?
<br />•
<br />El YES❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural d Homicide
<br />❑ Accident ❑ Wad ding hnlestigatjon
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OFINJURi
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f`LOCATIOI OF INJURY STREET & NUMBER, APT.NO.
<br />23a: DATE OF DEATH (Mo., Day, Yr.)
<br />September 11, 2023
<br />23b. DATE SIGNED (Ma4 Day, Yr.)
<br />September 21. 2023
<br />I28a. REGISTRAR'S SIGNATURE
<br />CITYfrOWN
<br />23c. TIME OF DEATH
<br />06:00 PM
<br />7o Ute bast of dry knowledge, death occurred at the time, date and place
<br />atdd due to pita causes) stated. (Signature and Title)
<br />Anthony F. 'Cook, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />El YES :;;❑ NO ❑ PROBABLY ® UNKNOWN
<br />27; NAME, TITLE AND ADDRESSOF CERTIFIER (Type or Print
<br />•At
<br />21b, IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />STAN
<br />Nebraska
<br />1Tb a Cods;;;
<br />68803 ...
<br />APPROXIMATE INTERVAL
<br />onset to -Baan(-
<br />1 HOUt
<br />onset to death
<br />Hours
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />YES ❑ NO
<br />21c. WAS AN AUTOPSY PERFORMS
<br />❑ YES
<br />21d. WERE AUTOPSY MNDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES 0 N
<br />ams, tarm,;street, factory, office building, construction site, etc:: sp
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr
<br />ZIP OODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />`24e On the basis of examination and/or investigation, In my opinion dasiir occurred at
<br />the time, date and place and due to the cause(s) stated. (slgneture anti telae) •
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 14 NO
<br />4nthony'F. Cook, MD, 2620 W Faidley Ave,' Grand Island, Nebraska, 68803.
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YES .
<br />NO ..
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) l
<br />September26, 2023
<br />
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