|
a,< STATE OF NEBRASKA
<br />ert.ttt,hahu -- rSdIIOlI111dd�`T` a �r9+i9u+0�� :.9ir644tiiflll�w•'> rrrrrr,+..
<br />elltwolt
<br />.111.0
<br />WHEN; THIS !'COPY CARRIES THE RAISED SEAL CIF HESTATE OF NEBRASKA, IT -
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD •
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN • SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITARY FOR VITALRECORDS
<br />11
<br />DATE OFISSUANCE
<br />3/19 /2020
<br />UNCO N NEBRASKA
<br />202 005
<br />�'fiiokteetket.
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGI
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />C TIFIC D T ... 20 02$58
<br />3. DATE OF DEATM(Mn., ISay m
<br />1 DtCEDENTS-NAME (First, Middle, Last, Suffix) •2. SEX
<br />Diana Sub Grantham Female February 27, 2020 .
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5e :AGE Lae(.Birthdeyi 5b UNDER 1 YEAR 5c. UNDER 1 DAY A. DATE OP BIRTH (Mo.,
<br />(Y») MOS. DAYS HOURS MINS.
<br />St,:; franc's, Kansas
<br />7..SOC)AL SECURITY:NUMBER
<br />509.48.2002
<br />'b.FACtUTY=NEME Qfriot institution, give street and wpm! r)
<br />• 0,
<br />Wedgewood Care Center
<br />Bc..CIT1 'OR TOWN OFDEATH (Include Zip Code)
<br />Grants IslNNiid 68:83
<br />91. RESIDENCE -STATE
<br />Nebraska
<br />9d.:;STREET AND NUMBER.
<br />409 East 14th Street
<br />9b. COUNTY
<br />Hall
<br />Se :PLACE OFDEATH :::.
<br />HOSPITAL (Inpetle t
<br />r1 FR'nutoadent
<br />❑ DOA
<br />10a.MARITAI„ STATUS.AT TIME OF DEATH fi(J Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11ATHERS.NAME (Firaet, Middle, Last,
<br />Z:harles :Lester .Browning
<br />9c. CITY OR TOWN
<br />Grandisland
<br />January 1:7;1950
<br />OTHER J Nursing Honr/LTC
<br />p Decedent's Nome
<br />p Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />APT. NO.
<br />10b. NAME OF SPOUSE (First; Middle,
<br />Dean Stewart Grantham Jr
<br />9f, ZIP CODE
<br />68801
<br />sfl
<br />Suffix) If wife,
<br />9}h DS ray. tArTS
<br />YES p.iuo
<br />mYd.n none,
<br />Suffix) 12. iltDTNER'S-MAME (First Middle, Maiden Surname
<br />Affiett6 Wolbach
<br />13."Ev.ER IN U•S ARiVEm FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />Burial [ Donation
<br />{ Cremation QEntolibment
<br />0 Remove{? p Other (Specify)
<br />14a. INFORMANT -NAME
<br />Dean Stewart Grantham Jr
<br />18a. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17e ;FUNERAL.t.OMENAME AND MAIUNG ADDRESS (Street, City or Town, State :
<br />All FAitht:Ftnietat Home, 2929 S. Locust Street. Grand lean& Nebraska._
<br />19b. LICENSE NO.
<br />1071
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH Seellittruttlotitatid examples)
<br />IL PART 1. Enter the chain of owls. dIssina, injuries, or compllcatlons4hat directly caused the death. DO NOT enter tenninel events such as cardiac angst,
<br />respiratory arrest, or ventricular fbrNbltlon without showing the etiology. DO NOT Aa9REVIA1E. Enter Only one dose on a line. Add additional Ones x necessary.
<br />IMMEDIATE CAUSE:
<br />MMEDIAresAU,04014) y re
<br />SINN* ar ooniMlon resusetq
<br />Sequentially Nst conditions, It
<br />any,: Leading to:th/;sautI.it$isd
<br />n:i[n► a.
<br />:: die NDE .vlNOCAtBE
<br />(eNasasbr InItitVlbat lifftlated
<br />the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Pneumonia•
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />14b- RELATIO
<br />Spouse
<br />'DECEDENT!:.
<br />1Sc. DATE Otto.; Diy,Yr.),
<br />March 2, 2020
<br />Nebraska
<br />t7ta
<br />68801.
<br />) APPROXIMATE INTERVAL
<br />WAWA ta i it
<br />11 !IRO .'
<br />onset to death
<br />110 Days
<br />18 ;PART IL OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the tie r
<br />Chronic Obstructive Pulmonary Disease, Heart Failure
<br />D. IF FEMALE::::
<br />Notpf+egnent wahie pipe year
<br />❑: Pregnant mem. dreads
<br />rot progniutt, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days tot year Were death
<br />❑ tifihnavm it pregnant whin the past year
<br />DA l oK RI(lURY (MO, Day, Yr.)
<br />ar
<br />INJURY AT WORK?
<br />OYES ;;ONO
<br />..:,:,.
<br />215. MANNER OF DEATH
<br />® Natural Q Nomiclels
<br />❑ Accident © Psndfng lmtsstigtitlon
<br />❑ Suicide 0 Coude not be determined
<br />natio
<br />22b. TIME OF INJURY
<br />22c
<br />22.. DESCRIBE HOW INJURY OCCURRED
<br />underlying canes given in PART I.
<br />210-4F. TRANSPORTATION INJURY
<br />; ❑ Diltisr/Oper„or
<br />©Pariiunaer
<br />0 Pedestrian
<br />p Other(Spacity)
<br />-r.
<br />CSOF INJURY•At home fent,:street, t
<br />22f:LOCATION 'OFINJURY ;' STREET 8, NUMBER, APT.NO. CITY/TOWN'
<br />19. WAS MEDICAL: EXAMMIEi4:
<br />ORCORONIER cOONtikett D? '..
<br />p YES la NO
<br />SIC. WAS AN AUTOPSY PERFORMED?
<br />❑
<br />YES EgIA9
<br />21d.WEREAUTOPSYFINDINGSAtiiii 1E
<br />TO COMPLETE.CAUSE OF DEATH? • .
<br />YES»
<br />boding, duction *its,'s
<br />STATE
<br />I23a. DATE OF DEATH (Mo., Day, Yr.)
<br />▪ { February 27, 2020
<br />23b. DATE SIGNED (Mo.. Day, Yr.)
<br />March 6::2020
<br />23c. TIME OF DEATH
<br />05:15 AM
<br />LON butt Nnowledge, death occurred at the tens, dote end play
<br />..idduetoMe'ousels) meted. (Signature and Title)
<br />Brandon Jahnke, MD
<br />25. DID TOSACCO USE CONTRIBUTE TO THE DEATH?
<br />12 YES ❑ NO 0 PROBABLY 0 UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />244. TIME OF DEATH
<br />24c. PRONOUNCED DeAD (Mo, Day. Yri 24d. Time PRONOUNCED DEAD.
<br />is
<br />4e Orrthe taeesof examination and/or eNestipaeeon, In my opinion /wrtit epee red LIE
<br />',swami, data and plata and duo to tet esuae(N stated. (atenetem ll (tel te)
<br />28a. HAS ciscAr4olrissua r • A11ON BEEN CONSIDERED?
<br />•
<br />Dyes . e
<br />27 NAME; =SAND ADDRESs OF CERTIFIER (Type or Print)
<br />Brandon Jahnke, MD, 301 S Way Aye, Sutton, Nebraska, 68979
<br />28a REGISTRAR'S SIGNATURE
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 255 is NO DIES
<br />❑`i
<br />
|