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<br />STATE OF NEBRASKA
<br />WHEN'7Hts COPY CARRIES 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 THS` t.="4/AL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />9/25/2023'
<br />LINCOLN, NEBRASKA
<br />202400027
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<br />SARAH BOHNENKA ' I'
<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 />Ramona :Jean Roberts
<br />4.`CITY AND STAT OR: TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Aurora, Nebraska
<br />7;SPC2A( SECURITY EUMBER
<br />506.40-0.401
<br />58.AGE - Last!alrfitdity
<br />(Yrs.)
<br />87.
<br />8b;.FAOitITY ,ME (If:not Institution, give street and number)
<br />CHI Health St. Francis
<br />8cGITYORTyWN OF DEATH (Include Zip Code)
<br />Grand latand 88803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d STREET AND NUMBER
<br />404 Woodland Dr<
<br />9b. COUNTY
<br />Hall
<br />Bb.:UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a, PLACE dE
<br />HOSPITAL :(4btpatlent
<br />0 ER/Outpatient
<br />❑DOA
<br />19a MARITAL STATUS; AT TIME OF DEATH J Married 0 Never Married
<br />Q Married, but separated Q Widowed 0 Divorced 0 Unknown
<br />11 FATHER $,NAME (First, Middle, Last, Suffix)
<br />l3enr11:OpOill:C Dunham
<br />13. EVER IN IJiS ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit) NO
<br />16. METHOD OF DISPOSITION
<br />121004e1 © Donation
<br />] CratrMd'on ©EntOsnbment
<br />Q Removal:;: QOttier (Specify)
<br />9e. CITY OR TOWN
<br />Grand Island
<br />IBd. COUNTY OF DEATH
<br />Hall
<br />HOURS
<br />MINS.
<br />12'.
<br />3. DATE QF DEATH 4194.Day, Yi
<br />Septernlr 12, 2Q23
<br />6. DATE OF BIRTH (Mo., Day, 3'f.)
<br />OTHER 0 Nursing Home&L1
<br />❑ Decedent's Hoe
<br />❑ Other (Spec
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If
<br />Wilbur Roberts
<br />12. MOTHER`S-NAME (First, Middle,
<br />Hannah Mae White
<br />14a. INFORMANT -NAME
<br />Brad Roberts
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />18b. LICENSE NO.
<br />CITY /TOWN
<br />Gibbon
<br />F IN$IDI„ OIT'Y LIMIT$,
<br />} VES ( NO
<br />14b RELATIONS€ IP TO DECIEDEN,
<br />Son
<br />16c. DATE(
<br />Septennber 13 2
<br />17a: FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town. State)
<br />Fill FaithsFuneral Home, 2929 S. Locust Street, Grand Island: Nebraska for
<br />Other (SDecifui
<br />CAUSE OF DEATH (See :(nstructions.and examples)
<br />1a. PART 1. Enter the chaih of events- diseases, injuria, or complications -that directly caused the death. DO NOT enter terminal events such u cardiac arrest,
<br />respiratory amen, or ventricular fibrillation without showing:the etiology. DO NOT ABBREVIATE. Enter only one cause on a One. Add additional linea N necessary.
<br />IMMEDIATE CAUSE:
<br />MED cAilE ( a) acute respiratory failure
<br />IM IATE Final
<br />wase er tion liton reaukinp
<br />kt'traafb)
<br />SequeMiaiy het conditions, if
<br />any, leading to the cause listed
<br />on
<br />theDti tiWINGCAUSE
<br />(diteeorior Initikihetkiftlated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)severe chronic obstructive pulmonary disease
<br />DUE, TO, OR AS A CONSEQUENCE OF:
<br />c) tobacco abuse
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />$TATE
<br />Nebraska
<br />is,:PART It. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART 1.
<br />severe sepsis, respiratory acidosis, hyperkalemia, acute kidney injury, cellulitis of arm, urinary tract infection, coronary artery
<br />disease,
<br />20. IF FEMALE:
<br />Q
<br />Not pmgnara wlI$n pea
<br />Pregnant at thI,e of f.afh .
<br />Q
<br />Not prsgnenf, but ptatm within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />224. DATE OFtNJUI
<br />Yi(M
<br />22d. INJURY AT WORK?
<br />❑YES El NO
<br />Day, Yr.)
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Hondcide
<br />❑ Accident ❑ Panphtg bwstigatien
<br />❑ Suicide ❑ Could not be determined`
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />❑ Dftver/Operator
<br />•❑ paessnger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office bull
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />'22t LOOMIONOF INJURY- STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 12, 2023
<br />CITYlrOWN>
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Ss l;en ber 13.2023 11:55 AM
<br />3d. Totke Nista knowledge,death occurred at the time, date and place
<br />end dui to the teuse(s) stated. (Signature and Title)
<br />JaVC. Anderson. MD
<br />1
<br />21c. WAS AN
<br />❑ YES
<br />21d. WERE AUTOPSYPIKOOSAVMLABLBLE
<br />TO OOMPt,ETE CAUSE OF MATH"
<br />❑ YES
<br />9, consul
<br />STATE
<br />CODE.;::
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRI
<br />IJNEE
<br />tie. tan the penia of examination endior instigation, in my opinion dart e',,,.
<br />the thila, date and place and due to the cause(s) stated. (Sighat lre'apd"T)
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE ' • TION,:BEEN CONSIDERED?
<br />YES ❑ NO ;:❑ PROBABLY ❑ UNKNOWN 0 YES RE
<br />27, NAME, ITtE AND ADDRESS OF CERTIFIER (Type or Print
<br />.jay4. Andersen MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />24a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO Q Y88
<br />❑N
<br />28b. DATE FILED BY REGISTRAR
<br />September 21, 2023
<br />(Mo., Day, Yr.)
<br />
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