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STATE OF NEBRASKA
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<br />IYHEN 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 OF ISSUANCE
<br />5/18/2028
<br />LINCOLN, NEBRASKA
<br />202400770
<br />SARAH BOHNENICAMP 'TI
<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 DECEDENi`RiAME tFhst, Middle, Last, Suffix)
<br />C ivi.ttt > arOa1( .Humphrey
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hastings,: Nebraska
<br />Sr c1ALsacunnYNUMBER
<br />,507-804973
<br />b. FACILITY -NAME (if net Institution, give street and number)
<br />Grand Island Regional Medical Center
<br />So.;CIYY OR'moot. OF DEATH (Include/Ip Code)
<br />Otani Island li68803
<br />IDENCE-STATE
<br />Nebraska
<br />ad..S11F#EET ANDNualBER
<br />2P3 Sou#h J i ad
<br />9b. COUNTY
<br />Hamilton
<br />IMAGE - Leet Birthday
<br />(Yrs.)
<br />77;
<br />5b+ UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Ile.PLACE OP DEATH
<br />HOSPITAL .j ftpatlent
<br />❑ ER)Ou patient
<br />Ej DOA
<br />104.' RITAL$T.ATUSATTIMEOF DEATH IE Married 0 Never Married
<br />tj Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. PA/HER S MAME (First
<br />Harold HumOhrev
<br />Middle, Last, Suffix)
<br />13. EVERIN U $ARMED FORCES?'Give dates of service if Yes.
<br />(Yes, No, or unto) Yes 09/25/1968-06/25/1971
<br />15, METHOD OF DISPOSITION
<br />❑<Burfat Donat(on
<br />:Cremation; ❑ Entombment
<br />❑'liemova( . []Otlter (specify)
<br />9c. CITY OR TOWN
<br />Giltner
<br />HOURS
<br />MINS.
<br />3 DATE OF DEATH (Mo., Day Yr)
<br />May 13, 2023
<br />6. DATE OF BIRTH (Mo., D
<br />December 8, 1945
<br />OTHER 0 Nursing Nome/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Pe. APT. NO.
<br />9f. ZIP CODE
<br />68841
<br />INSIDE CITY LIMITS
<br />DYES T4a
<br />IIIb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give m
<br />Janet Huohbanks
<br />14a. INFORMANT -NAME
<br />Janet Humphrey
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12. MOTHER'S -NAME (First, Middle, Maiden Sums
<br />Devonne Scobie
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />Iia. E.UNERAL'H.OME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Hiobv McQuiston Mortuary, no:, 1404 L Street, PO Box 204, Aurora, Nebraska
<br />18b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. RART 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 ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />AUSEIPInei a) Cardiopulmonary arrest
<br />dt>keabe or eondltlon resulting
<br />14b.,RELATIONSH(P TO DECEDENT?;
<br />Spouse
<br />18c. DATE (Mo., Day, Yr.),.
<br />May 14, 2623 ,
<br />51TA'tE
<br />Nebraska
<br />death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially ustconditions, it b) Septic shock
<br />any, leading to the ceusrl ilsted:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter*,ONDEAl;,YIN AU$6 C) Community acquired pneumonia
<br />(Meese* or injutythat ink&tted
<br />she eventsresulting In deaSi)
<br />LAST
<br />DUE TO, OR A CONSEQUENCE OF:
<br />d)Severe neutropenia
<br />APPROXIMAfiEINTERVAL
<br />t
<br />*death
<br />18 RART II oThER SteatFMCANT CONDITIONS -Conditions contributing to the death but notresulting In the underlying cause given in PART I.
<br />MuIflpta myelama
<br />20. IF FEMALE;:-
<br />dotpregnant ithinpastyaar
<br />[ iPtegnaat at bills of hearts
<br />rVot phl9naat bnt preghant wriMn 42 days of death
<br />❑ Plot pregnsmy but pregnant 4s dfiys tot; year before death
<br />tlnitnrwrn if preiRiebt Mille me pact year
<br />TE
<br />INJURYt
<br />22d. INJURY AT WORK?
<br />YES 0140
<br />Day, Yr.).
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ AccldeM ❑pending IrWeatigatjob
<br />❑ suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22e. PLACE OF
<br />iESCRIBE HOW INJURY OCCURRED
<br />22f LOCATION OF INJURY, STREET& NUMBER, APT.NO.
<br />23s. DATE OF DEATH (Mo., Day, Yr.)
<br />May 13, 2023
<br />CITY/TOWN":
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />fey 14, 2023 06:00 PM
<br />28d. To ilie ret of my knowledge, death occurred at the time, date and place
<br />end:dretothe:c usels)stated.(SignatureandTitle)
<br />Thamer Kassim, MD
<br />25. DID TOBACCO USE;.C.ONTRI'BUTE TO THE DEATH?
<br />YESNO] PROBABLY ❑ UNKNOWN
<br />21b. IF TRANSPORTATION INJURY
<br />orivH/OpeMor
<br />Passenger
<br />oPedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY P.
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGSAIiAit.A$LE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />JURY At hams,;rarm, street, factory, office building, construction'
<br />to -
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />°:CODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PROIi
<br />246. tin the basis of examination and/or investigation, in my opinionde
<br />die timer date and place and clue to the cause(s) stated. (SigMiit
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES EI NO
<br />21. NAME T(TLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Thamer Kassim, MD, 2300S 16th St, Lincoln, Nebraska, 68506
<br />28a. REGISTRAR'S SIGNATURE
<br />UNCED DEAD
<br />26b. WAS CONSENT GRANT
<br />Not Applicable If 26a is NO I'
<br />28b. DATE FILED BY REGISTRAR (
<br />May 16, 2023
<br />.,D
<br />Yr.)
<br />
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